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