Chief complaint: patient’s age, sex and presenting symptoms
History of the present illness
Relevant family history, social and environmental history
List of possible diagnoses from the patient history – explain why this list was chosen
Results of the neurological exam tailored to the patient history – detail what was done and why it was done, as well as the results of the examination
List of possible diagnoses from the neurological exam – explain why this list was chosen
Further blood and radiological tests – explain your choices
Final diagnosis – explain how and why this was reached
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