Over the past few days I’ve been posting about case formulation. While I’ve presented the abductive theory of method (ATOM) which is a process of inferring from phenomena to underlying causal mechanisms, it’s not the only way to develop a formulation. I posted on some of the other ways formulations can be developed, and today I’m going to describe a simplified formulation to show how it can work in practice. Don’t forget that when I write about patients I make sure details that can identify the individual are changed – or I describe a composite of several patients.
Robert is a 39 year old previously self-employed electrician who sustained a fracture of a his nondominant hand when he fell from a ladder two years ago. This fracture developed into a complex regional pain disorder type i which had been slowly resolving with the use of medication, functional restoration (graded daily use of the hand), and mirrorbox therapy. Robert presented for pain management assessment when his progress plateaued, and he became increasingly distressed.
He was assessed in a three-part comprehensive pain assessment in which he was seen by a pain management medical specialist, a functional assessor and a psychosocial assessor. He completed a set of questionnaires prior to the assessment which were used to ‘flag’ areas for closer investigation. Information was made available from the referrer (the GP), the case manager (clinical notes from the orthopaedic surgeon and initial physiotherapy treatment provider), and an initial workplace assessment which provided details of his work demands.
The medical assessment consists of reviewing his previous medical history, a full musculoskeletal examination, general ‘systems’ examination, current and past medications used for pain management, and pain specific examination. The purpose is to identify whether all the appropriate investigations have been completed, the appropriate medical treatments have been pursued, and the medication regime is rationalised. (more…)