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Long Case Presentation (Rob's template)

Updated: May 15, 2022



Name _____, aged ____ years, is a (Occupation or life role) who (something interesting). They were referred to (who and by) because of (pain condition). They had (expectations) of the consult today.


Name has the working pain diagnosis of (pain diagnosis) in the context of (pain precipitating factor e.g. injury). The pain presents with features of (nociceptive/neuropathic/nociplastic) factors and secondarily is (nociceptive/neuropathic/nociplastic) in nature. The primary pain generator differential diagnosis includes (give likely site and pathological cause) as suggested by. The pain has (inflammatory/red flags/radicular symptoms).


Name's (pain condition) has significant biomedical, functional, psychological and social impacts to their pain experience. These will be followed by a discussion of pain cognitions, goals, barriers and facilitators for recovery and then with a management plan.


Biomedical factors include (.....). Pharmacological factors to consider include (...). Features on examination to note include...


Functional factors include (....).

(Handedness, ADLs, driving/mobility, loss of previous function, loss of role)

(HAD roles)


Psychological aspects include (....)

(DTM SSS - Diagnosis, Treating team, Management, Stressors, Sleep, Suicide)


Social factors to consider include (....).

(HFEOADS - Home/family, Education/occupation, Activities, Drugs/alcohol/caffeine/sugar, Suicidality, Spirituality/culture)


There are also key pain cognitions to highlight with facilitators and barriers impacting recovery. These include....


Barriers to consider in X's pain management includes...

Positive facilitators of recovery for X includes...


In summary, predisposing factors include, precipitating factors include, perpetuating factors include, contributing factors include.


Our management plan will focus towards their main goals which are....


We will address these by:

Educational

Non-pharmacological

Pharmacological

Interventional methods


My follow up and prognosis for X includes:



 

HISTORY TAKING PAGES:


Demographics:



PAGE 1: Biomedical:

Pain Hx:


Rx's:


Functional impact:


PM/SHx:


FHx:



PAGE 2: Medications


Meds:


Past meds:


Allergies:



PAGE 3: SHx:

(HEADSS UP)



PAGE 4: Occupational Hx



PAGE 5: Psych Hx:

(DTM SSS)



PAGE 6: Cognitions/Goals

(Yellow flags)



PAGE 7: Examination:

 

Terms to consider:

Co-occurred with...

Exacerbated by

We might hypothesise that

Loneliness

Feelings of abandonment

Disproportionate responses to...

Abandonment

She is vulnerable to...

He has many acquaintances but few close friends

Negative preoccupations with

Feeling emotionally deprived

Dissatisfied with...

He feels incapable of...

Ruminations

Her thoughts may have been fomented by her religious upbringing...

They feel resentful towards...

Avoidance as a compensatory coping strategy

Self-efficacy and enjoyment

The person she rejects...

Worst-case scenario




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