Pain Consultation Initial

Subjective: Pain History: - List areas of pain. For each area of pain, note the characteristics of the pain, constant or not constant, radiation of pain, any other symptoms. Note the history of the pain. Note the possible causes of pain. If there has been an injury, a fall, or an accident, note all the details. Record in patient's own words how they describe their pain and the impact of the pain on their daily lives. Record if they have any expectations. Record any symptoms the patient may discuss. Use quotes whenever possible. If there is mention of accidents, injuries, record this. If there are headaches, be very specific about the characteristics of headaches, for example, throbbing, unilateral, or bilateral, location of headaches, photophobia, phonophobia, nausea, vomiting, worse with exertion, mild, moderate or severe. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Snoring: If there is mention of snoring, questions regarding snoring, record the answers and any associated information. Record any advice, warnings regarding snoring and opioids. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Past treatment: Make detailed notes in regards to past treatment such as medications, physiotherapy, psychology, psychiatry and any complications or side effects recorded. If there is information about past providers, past treatment and interventions, record all of that. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Additional information: Make detailed notes about everything the patient and I discuss during the consultation, and put this under Additional Information. Put any information that does not fit under headings into a new Heading called Additional Information. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Effect of Pain on their daily function: - Note if they affect their work. - Note if they affect their relationships. - Note if they affect their daily function such as showering, dressing, preparing meals, looking after children. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Mood and Sleep: Record details of mood, anhedonia, lack of motivation, energy, weight loss, weight gain, difficulty in sleeping, social withdrawal. If there is mention of suicidality, record this in the notes. If there are plans of suicide, record this in the notes. If there is mention of sleep limitations, record this. If discussing sleep, record number of hours of sleep. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Family History: Record any illnesses in the family. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Past Medical History and Surgical History: - Note if there are any medical conditions and how they have been treated, whether these conditions are treated and note any additional information if discussed. - Note if there were any surgeries and if any additional information regarding these surgeries. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medications: - Note any medications, dosages, effects, and side effects if discussed. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Allergies: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Cigarettes and alcohol history: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Objective: Record any findings discussed. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Imaging: - Note the type of imaging, date and the findings. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment: Differential diagnoses are: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: (Write as a numbered list) [Record any imaging ordered.] [Record whether any procedures have been planned, e.g., pulse radiofrequency, radiofrequency neurotomy. Record the location. Record if consent has been obtained and potential complications have been explained.] [Record any explanations regarding the management of pain. The role of depression, anxiety and poor sleep which may influence the perception of pain.] [Record any medications recommended.] [Record any other advice given.] [Record follow-up plans.] [Record any warnings regarding opioids, driving, alcohol, sleep apnoea, risk of low testosterone and osteoporosis. Record if an opioid consent has been signed.] [Pain Education] (If there are warnings and explanations of complications of medications, opioids and procedures, record this. Make detailed notes regarding any warnings and advice I give to the patient. Make detailed notes about education such as pacing, mindfulness, meditation, gentle exercise, online pain management course such as Mindspot. Record any discussion of physiotherapy and psychologist in the management of pain. If there is mention of snoring, questions regarding snoring, record the answer and any associated information. If there is advice or warnings regarding treatment of sleep apnoea, driving, record this.) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)