MS Relapse Assessment

**Patient Concern:** [patient's primary concern or reason for call or visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Current Symptoms:** [detailed description of current symptoms including onset, duration, progression, severity, and characteristics] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) [description of any precipitating factors, triggers, or recent stressors] (If precipitating factors, triggers, or recent stressors are mentioned in the transcript, contextual notes, or clinical note, describe them. Otherwise, state that no recent precipitating factors were reported.) [comparison to previous episodes or baseline functioning] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Review of Systems:** **Related Symptoms** **Vision:** [vision issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Balance and Coordination:** [balance and coordination issues and any related advice or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Motor - Upper Limbs:** [upper limb motor symptoms and any related advice or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Ambulatory - Lower Limbs and Mobility:** [lower limb motor symptoms and mobility issues and any related advice or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Pain:** [pain issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Sensory:** [sensory symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Bladder:** [bladder issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Bowels:** [bowel issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Speech and Swallow:** [speech and swallow issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Cognition:** [cognitive issues and interventions, advice, or referrals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Fatigue:** [fatigue symptoms and any related advice] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **In Summary:** [neurological symptoms documented] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) [constitutional symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) **Past Medical History:** [diagnosis date and initial presentation] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write in paragraph format.) [previous episodes with dates and symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) [other relevant medical conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Current Disease Modifying Treatment and Symptom Management Medications:** [disease-modifying therapies with dosages and duration] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) [symptomatic treatments and other medications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) [medication adherence and any recent changes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Last Imaging:** [type of imaging] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) [date of imaging] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) [imaging findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) [imaging requests] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Paraclinical Results:** [relevant laboratory results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) [date of results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) [context of results] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit this line completely.) **Physical Examination:** [vital signs] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) [general appearance and mental status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) [detailed examination findings including relevant neurological assessments] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) [functional assessment scores if performed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Assessment:** [clinical impression regarding current symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write in paragraph format.) [severity assessment and functional impact] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in paragraph format.) **Plan:** [treatment recommendations including any interventions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) [diagnostic testing] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) [follow-up arrangements and monitoring plan] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.) [medication adjustments or disease-modifying therapy considerations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points.)