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Approach To History Station

This document outlines the structure and approach for a history station encounter. It includes sections for greeting the patient, taking a history of present illness, past medical history, drug history, family history, social history, and developing a summary and concerns. The encounter is designed to gather relevant clinical information from the patient in a structured format to inform the clinician's diagnosis and management plan.

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ibra musa
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112 views2 pages

Approach To History Station

This document outlines the structure and approach for a history station encounter. It includes sections for greeting the patient, taking a history of present illness, past medical history, drug history, family history, social history, and developing a summary and concerns. The encounter is designed to gather relevant clinical information from the patient in a structured format to inform the clinician's diagnosis and management plan.

Uploaded by

ibra musa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

History Station

Approach of History Station


 Greating & introduction:
o Hello  , I am Dr ……, ….. , nice to meet you.

o Are you Mr/Ms ….


o I have received a letter from your GP that you have ……. , I am sorry for that 
o Could you please tell me more about that 

 HPI:
o Analysis of complain  OCD, ↑, ↓, association & timing.
o If pain  SOCRATES: nature, radiation & score.
o Is that first time to occur with you! If recurrent → is it the same character or different?
o Analysis of the system related to that complain: cardio, chest, GIT, Neuro, Rheuma…
o DD
o Review of systems:

 Structure:
o PMH (Past Medical History):
 Specific disease: Could you tell me more about your health in the past?
 Hospitalization.
 Operation. Female: 5 P:
 Period:
 Blood transfusion.
o Regular
 Allergy. o Amount
o When Last one
o DH (Drug History): show me your medication list 
 Partner
 Compliance.  Pills
 Recent change of the dosage.  Pregnancy
 Abortion: number, time.
 Side effects.
o FH (Family History):
 Similar condition runs in your family?
 Specific disease runs in your family?
 Any family history of note?  Cancer / sudden cardiac death.
o SH (Social History):
 Smoking: How many? For how long? → I will refer you to Smoking cessation clinic
 Alcohol: How many units/wk? What about week ends?, CAGE → I will refer you to
Alcohol cessation group support.
 Job: What do you do for living?, any recent change of your Job?

Dr Mohd Hassan LOVE PACES


History Station

 Impact of that complain on your job or your daily activity → I will contact your
Occupational health physician.
 Financial support? → I will refer you to Social worker.
 With whom are you living? I will refer you to Social worker.
 Driving → Hold driving & inform DVLA.
 Sex: are you in long term intimate relationship?
 HIV risk
 Travel.

 Summary: if there is anything else you would like to add 


2 minutes remaining
(At this point you have to reach to Diagnosis or DD)

 Concern:
 Clinical communication: (= Discuss management plan):
o Admission  MDT 
o Investigations: Labs & Imaging.
o TTT: non pharmacological & pharmacological.

 Do you have any other concerns

 Thank you 

Dr Mohd Hassan LOVE PACES

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