This is a presentation made by MSU students to be presented to the specialist during their posting in HRPZII Kota Bharu, Kelantan.
Very good summarised guide for PLAB 2
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Case Taking
History Taking Performa P3 MAFTOSA P – Presenting complaint (SOCRATES / ODPARA) P – Past Medical History P – Personal History M – Medical History A – Allergy History F – Family History T – Travel History O – Occupational History S – Social History A – Anything Else you would like to tell me?
1 – PRESENTING COMPLIANT:
SOCRATES (only for pain) Or
AND Differential diagnosis.
ODPARA (for other symptom) SOCRATES
S – Site: Where is the pain, can you show me with one finger? O – Onset: How did it start? Suddenly or Gradually?
ache/compressing/sharp? rp? C – Character: What type of pain is it? Dull, ache/compressing/sha R – Radiation: Does the pain go/move anywhere? A – Associated: Differential Diagnosis T – Timing: Is there any specific time you experience the pain or when is it worse? Is it
always there or it comes and goes? E – Exacerbating & Relieving factors: Is there anything that makes the pain worse? Is there
any thing that makes the pain better?
S – Severity / Score: On a scale of 1 – 10, 1 being the lowest and 10 being the highest, what
is the score of your pain? ODPARA O – Onset: How did it start? Sudden or gradual? D – Duration: When did it start? Or how long have had these symptoms for? P – Progression: Is it becoming worse, improving or is it the same? A – Aggravating factors: Anything which is making it worse or anything which is brining it
on(if intermittent symptoms)? R – Relieving factors: Anything which makes it better? A – Associated symptoms: Differential diagnosis
2 – PAST MEDICAL HISTORY: 1) Do you have any medical condition? 2) Have you ever been admitted to hospital for any reason? 3) Have you ever had any operations done on you? 4) Do you have any medical condition like Asthma, High blood sugar/ High blood pressure/IHD/ Epilepsy/stroke?
3 – PERSONAL HISTORY: 1) Do you smoke? 2) Do you drink? I need to ask you a few personal questions – 1) Is there any chance you use recreational drugs? 2) Sexual history: a. Are you sexually active? b. Is your partner male / female?
If relevant
c. Do you practice safe sex? Do you use condoms? 3) For Females: a. When was your LMP? b. Are your periods normally regular? c. How long do they last? d. After how many days do they repeat? e. Do you pass any clots? f.
Do you use any type of contraception?
If relevant
4 – MEDICATION HISTORY: 1) Are you taking any regular medication? 2) Are you taking any over the counter (OCT) medication? 3) Are you on any type of contraception (for females of reproductive age only)?
5 – ALLERGY HISTORY: 1) Are you allergic to anything? 2) Are you allergic to any medication? 3) If yes: What happens when you take it?
6 – FAMILY HISTORY: 1) Anyone in the family with similar conditions or problems? 2) Anyone in the family with heart problems, high BP, high blood sugar levels or Asthma?
7 – TRAVEL HISTORY: 1) Have you travelled abroad recently? 2) If yes, where did you travel?
8 – OCCUPATION HISTORY: 1) What do you do for living? 2) Are you retired? What did you use to do for a living?
9 – SOCIAL HISTORY: 1) Who do you live with? 2) Do you live in a house or a bungalow? 3) Do you walk independently? ( for eldely patients)
10 – ANYTHING ELSE: 1) Is there anything else you would like to tell me about your condition?
PAEDIATRIC HISTORY: 1) Any problems during pregnancy? 2) Any problems during birth? 3) After how any days did you go home after your after one was born?
4) Did your child need any help with breathing? Or did he need any type of special care? 5) Are you happy with the way your is developing? 6) Is he/she upto date with all immunisation? NB:- Ask these questions after taking full history of the presenting complaint
RELEVANT HISTORY: If the question says take relevant history, then ask the presenting complaint and differential diagnosis only.
Take history and give diagnosis/differential diagnosis to the examiner= P3MAFOSA Management with the patient leave enough time atleast 2 minutes. Management with the examiner you leave 30 seconds.
