Guidance for history station

It is a long time, I haven't written anything on this blog, as I was on holiday to India for Diwali and couldn't find time and Internet to write.

When I did my exam, I failed first time and I tried to analyse things and found that you can not guess or know what will come in the exam, but if you have systemic proforma which will cover almost everything then there is good chance that you will do well even if you don't know much about the station. I made this format for myself, but thinking that if I will publish this more people will use this. Below format will help you with stations which include history (brief and detail), examination and management. One of my facilitator in one course told me one day, that there is no such thing as brief or detail history. He suggested that I should include as much information needed for the station (certainly asking basic details like medication, past history and allergies etc are necessary for every station).

History station:

ü      Basic information: Name, Age, Sex, Independency and living situation

ü      Presenting complain

ü      HPC: Description of PC (PQRSTA)

·         Position

·         Quality/character

·         Relieving/aggravating factors

·         Risk factors

·         Radiation to other part (imp for Pain)

·         Severity/intensity

·         Setting/context

·         Timing

·         Associated features

ü      Other current Medical Problems

ü      PMHx

ü      If Paediatrics: Includes Pregnancy Hx , birth Hx, growth and development Hx

ü      Includes preventive history: Vaccination, Pap smear, Mammogram

ü      If Female (O and G): Periods, Pregnancy, Pap smear, Breast and Vaccination (Rubella, VZ, Gardasil etc).

ü      Medications includes ‘over the counter’, Herbal and vitamins

ü      Allergies

ü      Systems review – Head to toe

ü      Family Hx including spouse if indicated

ü      Social Hx: Living situation, Independency, Marital Hx, children, Smoking, Alcohol and other drug abuse

ü      Psychiatric history

Physical examination station:

General appearance

Vitals – temperature, pulse, BP, RR and Saturation

Skin, hair, nail

ENT and eyes

Neck, Thyroid and lymph node

Respiratory

Cardiovascular

Abdomen – always includes inguinal region, genital examination and PR examination 

UL and LL - Periphery

Includes office tests

ECG

BSL

Urine dipstick

Pregnancy test

Spirometry

Bladder scan

Management station:

Education and explanation

Initial management: stabilisation and emergency

Investigation

Management: drug management, procedure, non-drug treatment

Education, counselling and preventive

Family involvement

Referral to specialist/hospital

Ongoing management: follow up

Paperwork – Sick certificate, notification etc.

Please read disclaimer before using above information.