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Clinical history and work up

Updated: Feb 6, 2021


Demographic data:

Name, Age, Location


Referral source:

GP/Specialist/Follow on

 

Summary and Formulation:

An introductory statement of salient demographic data. A brief summary of the most important features of history and examination. Diagnoses.

- Predisposing - Precipitating - Perpetuating - Aggravating

- Relieving factors


Sophisticated formulations illustrate

  • How influential are these factors?

  • How do they relate to the disease, suffering and function of the patient

  • What are the dynamic interaction of the biological, psychological and social components of the case (e.g. what psych things may stop them doing therapy)

  • How may these things affect long term outcomes

Management plan (immediate, short and long term)

- Non-professional influences / care providers (e.g. family)

- Involvement of allied health

- Pharmacological and medical follow up including referrals

- Procedures recommended

- Consider limitations in management (e.g. medication unavailable)

- Follow up planning

 

Presenting complaint:


History of presenting complaint:

(LINDOCARRF - remember intensity at rest and activity)


Impact of pain on life: (ADLs, Social)


Current and past pain treatments: (Pharmacological, interventional, psychological/allied health, complementary, OTC)


Occupational impact and history: (Including legal/claims, past jobs, current financial income etc).


PMHx/PSHx (other):


Medications (Analgesia):


Medications (Other):


Allergies:


Family history: (If relevant)


Social history: (HEADSS) (don't forget substances)


Psychological history:

- Formal diagnoses

- Supportive factors (Coping, Self efficacy, Locus of control)

- Maladaptive factors (Catastrophising, Fear avoidance)

- Suicidal screen


Forensic history: (if relevant)


Examination

  • Physical – pain orientated, functional and other relevant

  • Mental state

Investigations

  • Positive and negative, past and pending or to be ordered

Diagnostic List (with Taxonomy Framework) - (IASP, DSM 5, ICD-11)


 

Terminology to utilise:


High external or internal - Locus of control:

Pain generator:

Coping strategies:

Catastrophising:

Adaptive and maladaptive strategies:

Fear-avoidance behaviours:

Passive versus active treatments:

Social withdrawal:

Uses aids and displays pain:

Negative cognitions: (High external locus of control)

Positive cognitions: (Divert, self 'talk', ignore)

Self-efficacy:

 

2-1-3 - Discuss the application of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) concepts to people experiencing pain.

2-1-10 - Adapt assessment techniques to vulnerable populations, including but not limited to: 􏰀- Children - Older persons

- Persons with cognitive, behavioural, mobility or communication impairments

- ATSIH


2-1-16 - Describe the differences between active and passive modalities of therapy.


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