Fampridine first eligibility assessment

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