History Station Sample

• Introduce yourself, confirm the patient’s name and age, and obtain consent to proceed.

• “What brings you in today?”
• Confirm the main complaint: abdominal pain.

• Onset: “When did the pain start?”
• Duration: “How long have you been experiencing this pain?”
• Location: “Where exactly is the pain located? Is it in the upper, middle, or lower abdomen, or more towards the sides?”
• Nature: “Can you describe the pain? Is it sharp, dull, cramping, or burning?”
• Severity: “On a scale of 1 to 10, how severe is the pain?”
• Radiation: “Does the pain radiate to other areas, such as the back, chest, or shoulders?”
• Timing: “Is the pain constant, or does it come and go? If it comes and goes, how often do you experience it?”
• Aggravating factors: “Is there anything that makes the pain worse, such as eating, movement, or certain positions?”
• Relieving factors: “Does anything help relieve the pain, such as rest, medication, or certain positions?”
• Associated symptoms: “Have you noticed any other symptoms, such as nausea, vomiting, diarrhea, constipation, bloating, fever, or weight loss?”
• Previous episodes: “Have you had similar pain in the past?”

• Gastrointestinal: “Any changes in your bowel habits, such as diarrhea, constipation, or blood/mucus in your stool?”
• Urinary: “Any urinary symptoms like pain during urination, increased frequency, or blood in the urine?”
• Gynecological (if applicable): “For female patients, any recent changes in your menstrual cycle, abnormal vaginal bleeding, or pain during intercourse?”
• Systemic: “Have you experienced any fever, chills, night sweats, or unexplained weight loss?”

• Gastrointestinal causes: “Have you had any recent changes in your diet, or any history of conditions like gastritis, peptic ulcers, or irritable bowel syndrome?”
• Infection: “Any recent episodes of gastroenteritis or urinary tract infections?”
• Inflammatory conditions: “Do you have a history of inflammatory bowel disease, such as Crohn’s disease or ulcerative colitis?”
• Gallbladder or liver disease: “Any history of gallstones, liver disease, or jaundice?”
• Pancreatitis: “Do you have a history of alcohol use or pancreatitis?”
• Renal or urinary tract issues: “Any history of kidney stones or urinary tract infections?”
• Gynecological causes (if applicable): “Do you have a history of ovarian cysts, endometriosis, or pelvic inflammatory disease?”

• Chronic conditions: “Do you have any history of gastrointestinal diseases, kidney problems, or gynecological conditions?”
• Previous episodes: “Have you experienced similar abdominal pain in the past? If so, what was the cause?”

• “Have you had any surgeries involving your abdomen, such as appendectomy, gallbladder removal, or hernia repair?”
• “Any history of trauma or injuries to your abdomen?”

• “Does anyone in your family have a history of gastrointestinal diseases, kidney problems, or similar abdominal pain?”
• “Any family history of conditions like inflammatory bowel disease or gallstones?”

• Smoking: “Do you smoke or have you smoked in the past? If so, how much and for how long?”
• Alcohol: “Do you drink alcohol? If so, how much and how often?”
• Occupation: “What do you do for a living? Any exposure to chemicals or physical strain?”
• Diet: “What does your diet consist of? Have you made any recent changes to your eating habits?”
• Physical activity: “Do you engage in regular exercise? Any recent changes in your physical activity level?”

• Allergy: “Any known drug allergies?”
• Medications: “Are you on any regular medications, including over-the-counter pain relievers, antacids, or herbal remedies?”
• Recreational drugs: “Do you use any recreational drugs?”

• Travel history: “Have you traveled recently? Any concerns related to your abdominal pain, such as exposure to new foods or infectious diseases?”
• Vaccine history: “Are your vaccinations up to date?”
• Sexual history: “Any recent changes in your sexual activity that might be relevant (e.g., sexually transmitted infections)?”

• Gastrointestinal: “Any nausea, vomiting, heartburn, or changes in bowel habits?”
• Urinary: “Any pain during urination, blood in the urine, or changes in urinary frequency?”
• Gynecological (if applicable): “Any recent changes in your menstrual cycle, abnormal vaginal bleeding, or pain during intercourse?”
• Musculoskeletal: “Any joint pain, muscle pain, or weakness?”
• General: “Any fatigue, fever, or unexplained weight changes?”

• “What do you think might be causing the abdominal pain?”
• “Is there anything specific you’re worried about?”
• “What are you hoping to achieve from today’s consultation?”

“Mr. John Thompson is a 45-year-old male who presents with a two-day history of constant, severe abdominal pain, primarily located in the epigastric region. The pain radiates to his back and worsens after eating. He rates the pain as 8 out of 10 in severity. He also reports associated nausea and vomiting, along with a mild fever that occurred yesterday. There is no change in bowel habits, and he denies any urinary symptoms.
Mr. Thompson has a history of pancreatitis, which occurred about a year ago, and he is concerned that this episode might be a recurrence. He consumes alcohol regularly, typically 4-5 drinks on weekends, and has a past smoking history of 20 years, although he quit five years ago. He does not take any regular medications and has no known drug allergies.
His past medical history is notable only for the previous episode of pancreatitis, and he has no history of surgeries. There is a family history of gallstones in his father.
On further review, he denies any recent travel, significant dietary changes, or recent illness. His systemic review is otherwise unremarkable, except for the nausea, vomiting, and mild fever.
Given his history, alcohol consumption, and current symptoms, acute pancreatitis is the most likely diagnosis.”

• Acute pancreatitis
• Cholecystitis
• Hepatitis
• Ascending cholangitis
• Pneumonia
• Myocardial infarction

• Laboratory Tests:
  • Elevated serum amylase and lipase (more specific).
  • Elevated liver enzymes if gallstones are involved.
• Imaging:
  • Ultrasound: Identifies gallstones.
  • CT Scan: Confirms diagnosis, assesses severity, detects complications (e.g., necrosis, abscess, pseudocyst).

• Supportive Care: Mainstay of treatment.
  • Fluid Resuscitation: Aggressive IV fluids to maintain hemodynamic stability.
  • Pain Management: Opioids or other analgesics.
  • Nutritional Support: Early enteral nutrition preferred; nasojejunal feeding if necessary.
• Specific Treatments:
  • Gallstones: ERCP if cholangitis is present or persistent biliary obstruction.
  • Infection: Antibiotics if infected necrosis is confirmed.
  • Surgery: Indicated for complications such as necrosis, abscess, or pseudocyst.

• P: PaO2 < 8 kPa
• A: Age > 55 years
• N: Neutrophilia, WBC > 15,000/mm³
• C: Calcium < 2 mmol/L
• R: Renal function, Urea > 16 mmol/L
• E: Enzymes, LDH > 600 U/L, AST > 200 U/L
• A: Albumin < 32 g/L
• S: Blood sugar > 10 mmol/L