MULTIPLE SCLEROSIS – FAMPRIDINE ELIGIBILITY ASSESSMENT
PATIENT DETAILS
Full Name: John Smith
Date of Birth: 12/03/1978
Age: 46
NHS Number: 1234567890
Hospital/CH No: CH12345
MS DETAILS
Date of Diagnosis: 01/01/2010
MS Subtype: Relapsing-Remitting MS
Current DMT: Interferon beta-1a
Relevant Past Medical History: Hypertension, controlled with medication.
Current Medications: Interferon beta-1a, Lisinopril 10mg daily, Vitamin D supplement.
Allergies: No known allergies.
FUNCTIONAL SCORES
EDSS Score: 6.0
Assessed: 20/10/2024
9-Hole Peg Test – Dominant Hand: 35 seconds
9-Hole Peg Test – Non-Dominant Hand: 40 seconds
Digit Symbol Substitution Score: 45
Timed 10m Walk: 12 seconds
Assistive Device: Walking stick
ELIGIBILITY CHECKS
Ambulates ≥8 m: Yes
No History of Seizures: Yes
eGFR ≥50 mL/min/1.73m²: Yes
No Contraindicated Medications: Yes
CLINICIAN NOTES
Patient presents today for assessment of eligibility for Fampridine. Patient reports worsening mobility over the past 6 months. Examination reveals increased spasticity in lower limbs. EDSS score has increased from 5.5 to 6.0. Patient ambulates with a walking stick. Discussed the benefits and risks of Fampridine. Patient understands the potential side effects and is keen to try the medication.
PLAN
Prescribe Fampridine 10mg twice daily. Arrange follow-up appointment in 3 months to assess efficacy and monitor for side effects. Review blood pressure at follow up.
AUTO-ELIGIBILITY SUMMARY
Patient meets the criteria for Fampridine eligibility based on the assessment.
Dr. Emily Carter
Consultant Neurologist
Date: 01 November 2024
MULTIPLE SCLEROSIS – FAMPRIDINE ELIGIBILITY ASSESSMENT
PATIENT DETAILS
Full Name: [patient's full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Date of Birth: [patient's date of birth] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Age: [patient's age] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
NHS Number: [patient's NHS number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Hospital/CH No: [patient's hospital or clinical history number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
MS DETAILS
Date of Diagnosis: [date of multiple sclerosis diagnosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
MS Subtype: [multiple sclerosis subtype] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Current DMT: [current disease modifying therapy for multiple sclerosis] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Relevant Past Medical History: [relevant past medical history pertaining to multiple sclerosis or overall health] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Current Medications: [all current medications including over-the-counter and supplements] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Allergies: [known allergies to medications, food, or environmental factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
FUNCTIONAL SCORES
EDSS Score: [Expanded Disability Status Scale score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Assessed: [date EDSS score was assessed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
9-Hole Peg Test – Dominant Hand: [time in seconds] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
9-Hole Peg Test – Non-Dominant Hand: [time in seconds] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Digit Symbol Substitution Score: [score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Timed 10m Walk: [time in seconds] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Assistive Device: [description of assistive device] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
ELIGIBILITY CHECKS
Ambulates ≥8 m: [eligibility status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
No History of Seizures: [eligibility status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
eGFR ≥50 mL/min/1.73m²: [eligibility status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
No Contraindicated Medications: [eligibility status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
CLINICIAN NOTES
[detailed clinical notes from the assessment, including patient presentation, discussion points, and relevant observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
PLAN
[proposed plan for patient care, including further investigations, treatments, referrals, and follow-up] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
AUTO-ELIGIBILITY SUMMARY
[summary of fampridine eligibility assessment based on transcript, contextual notes or clinical note] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Clinician full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
[Clinician professional title and speciality] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Date: [date of the assessment] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit entirely. Never generate or assume patient details, assessments, plans, interventions, or follow-up. Use only transcript, contextual notes or clinical note as reference. If information is not explicitly mentioned, omit the section without stating that it is missing.)
