PLAB2 STRUCTURES

CONTENTS
No. Topic Page
1 INTRODUCTION 1
2 GENERAL APPROACH 3
3 STRUCTURE OF MEDICINE STATIONS 8
4 STRUCTURE OF PAEDS STATIONS 9
5 STRUCTURE OF SURGERY STATIONS 10
6 STRUCTURE OF OBS&GYNAE STATIONS 11
7 STRUCTURE OF PSYCHIATRIC STATIONS 12
8 STRUCTURE OF COUNSELLING STATIONS 13
9 MISCELLANEOUS STATIONS 14

INTRODUCTION
GENERAL INSTRUCTIONS
1. NORMAL CONSULTATION
History Taking
↓
Examination
↓
Investigation
2. ISSUES – You need to recognize issues and priorities
3. TIME – Show time management
4. FINDINGS – Identify significant findings or results – from history, exam or data
interpretation
5. EXAMINATION – Physical exam competently
– Use instruments well
6. DIAGNOSIS – Make correct working diagnosis
– Give appropriate diagnosis
7. MANAGEMENT – Management plan reflecting best practices
– Follow up
– Safety netting
– Leaflet
– Signs/Symptoms
8. RAPPORT – Empathy
– Sympathy
 – Patient-centered, reach an agreement with patient
– Demonstrate the ability to conduct a patient centered consultation
– Use verbal and non-verbal skills
9. LISTENING – Good listening
– Listen to answers and act on them
– Demonstrate you understand
10. LANGUAGES – Use languages that are relevant and understandable to patient
– No medical jargon

SCENARIO
Where you are: You are the FY2 working in a GP surgery
– Junior Doctor
– Know your level/limits
– Escalate to seniors
Who patient is: James Brown, aged 50, presents with visual problem
GPs: – Sees patient with minor or chronic health issues
– Cannot admit here
– Do investigations + arrange appointments to discuss result
– Starts treatment, follow up
OTHER INFO ABOUT – Nil significant past history and is on no medication. This is the first
PATIENT time you have seen him
WHAT YOU MUST DO – Assess the patient and inform him of your next management
– History – Focused
– Examination
– Investigation
*No CT-scans in GP => Read up ‘Function of a GP’
*Only refer to a specialist when you are sure of diagnosis
GP questions tests your ability to refer

SUMMARIZING TECHNIQUES
When you need to summarize:
1) At the end of taking the history
2) At the end of discussion of management
Questions Asked
1. You have told me you had palpitations that started 5 months ago….
- Is there anything I have missed
2. So, we have had a discussion that the palpitations you have might be due to ….
- That we will do ….. test
- ………………………medications
- ………………………follow up
- ……………………..safety net
- I’ve explained that……….
- We have discussed that ……….
Lastly – Is there anything else you want to ask me?
GENERAL APPROACH
GRIPS (Spend first 1.5 minutes on this)
*G Greeting the Patient
*R Rapport
- Call the patient by their name
- Shaking hands
- How are you doing?
- Eye contact
- Sympathy & Empathy
*I - Introducing yourself to the patient
- Identifying the patient
*P - Purpose of Consultation
- Patient Privacy & Chaperon (if needed)
*S - Social courtesy – Smile, sympathy, empathy

STRUCTURE
HISTORY TAKING
↓
ICE
↓
EFFECT OF SYMPTOMS ON PATIENT’S LIFE
↓
EXAMINATION

HISTORY TAKING

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?

SOCRATES
S – Site: Where is the pain, can you show me with one finger?
O – Onset: How did it start? Suddenly or Gradually?
C – Character: What type of pain is it? Dull, ache/compressing/sharp?
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?

ODIPARA
O – Onset: How did it start? Sudden or gradual?
D – Duration: When did it start? Or how long have had these symptoms for?
I - Intensity
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 bringing it on (if
intermittent symptoms)?
R – Relieving factors: Anything which makes it better?
A – Associated symptoms: Differential diagnosis

PAST MEDICAL HISTORY

1) Medical Condition
2) Hospital Admission
3) DM, HTN
4) Operations
Sign post – 1) I need to ask you about your general health
(It is a usual Q we ask) – 2) I need to ask about your general well being
– Do you have any medical condition – FIRST
– Then ask for specific – DM (high blood sugar), HTN (high blood
pressure), asthma, Epilepsy, strokes, heart problems

FAMILY HISTORY – Be specific, e.g., Is there anybody in the family with heart problem,
stroke, clot in leg, epilepsy, etc.

TRAVEL HISTORY: – Recent travel abroad in the last 6 months, 1 year

– Activities abroad
– Further questioning depending on the differential, e.g., abnormal LFTs
Hep A – did you eat in a restaurant
Last 1 year
– Sexual
– Operation
– Blood transfusion

OCCUPATIONAL – Maybe asked with social history

– What do you do for a living
– What did you use to do
ALLERGY – Are you allergic to anything?
– What happens when you take/use it?
a) Allergy to medications – Are you allergic to any medications
b) Other allergy – Do you have any other allergies

SOCIAL HISTORY – Can you tell me who is at home with you? Or Who do live with?
– Are you married?
– Where do you live – mobility, walking aid
– Help with daily routine
– Children: Do you have children
– Diet history
– Lifestyle
– Smoking
– Alcohol
– Stress: Is there anything causing stress
– Hobbies: What do you do in your free time
– Coping at home: How are you coping at home with general activities
– Family members: Who else is at home
– Mobility => Walking independently or with aid, washing, cooking,
bathing

ANYTHING ELSE => DIFFERENTIALS

– Summarize first before asking anything else (Do only when things are not clear or when you feel
something is missing
– Is there any other important thing I should know?

SYSTEMIC REVIEW
Ask after differential diagnosis.
1) CVS – Chest pain
– Palpitations – Racing of the heart
– Orthopnoea (shortness of breath at night/on lying down)
– Dizziness
– Breathlessness
– Ankle oedema
– Claudication
CHEST PAIN – Are you experiencing chest pain?
BREATHLESSNESS - Any when you lie down?
2) GIT – Appetite – How is your appetite
– Weight loss/Gain
– Do you feel you have gained weight
– Have you lost weight? Is it intentional?
–Nausea & Vomiting
–Haematemesis
 –Bowels – Frequency
–Abdominal pains
–Indigestions
3) CNS –Headaches
–Fits, Loss of Consciousness
–Dizziness
–Numbness/weakness
–Eyesight – any vision problem?
–Hearing
4) RESP –Cough
–Breathlessness
–Wheeze
–Sputum – Any phlegm? Blood?
–Haemoptysis
5) GUS –Urinary symptoms
–Dysuria
–Haematuria
–Frequency – waking up at night
–Incontinence
–Nocturia
–Terminal dribbling
–Hesitancy
–Discharge from penis or vagina
–Periods
–Dyspareunia
6) MSS – Joint pain
– Rash
7) OTHERS – Lumps and bumps anywhere

WHEN TO DO SYSTEMIC REVIEW

1) When things are not clear to you
2) Multiple system involvement, e.g., cancer
– Dehydration, Dysphagia

ICE (comes after history taking before examination, patient centered communication)

I-Ideas – What the patient thinks is the problem

– What do you think is going on?
– What do you think might be the problem
– What do you think is the cause of this symptom?
C-Concerns – What is the patient worried about?
– Do you have any particular worries about your symptoms?
E-Expectations – What the patient wants to get out of the consultation?
(depends on the – What were you hoping I was going to do for you today as a doctor?
scenario) – What do you expect to get out today?

ADMISSION – We recommend you stay in the hospital……What do you think about that?

MEDICATION – I was thinking of starting you on…..What do you think about that?
SIDE EFFECTS
– Will this be okay for you?
– Will you be happy with this?
– I will recommend you stay off this medication
=> JUST GATHER, BUT MAKE USE OF ALL YOU GET IN MANAGEMENT

I -Patient says he thinks it is an infection

DR -Alright
E -Do ask in acute scenarios, not all the time
-Is there anything else I can do for you? (Ask in management)

EFFECT OF SYMPTOMS ON PATIENT’S LIFE

1. Job – Has this affected your job?
– Will you say this has affected your job?
2. Sleep – How is your sleep?
– Do you think your sleep has been affected?
3. Daily Activities – Has this changed the way you go about your daily activities?
– How has this symptom affected your daily activities?
– Have you had to change the way you do things in your day to day
activities
4. Relationships – What does your partner think about this
– Is your partner supportive?
– What does your partner feel about the symptoms
– Do you think your partner has been affected?

SIGN POSTING – PERIODS

↓ – SEXUAL ACTIVITIES
Warning Shots – RECREATIONAL DRUGS
– CANCERS

BEGINNING
So can you tell me about your chest pain
Now I need to ask you a few more questions so I can help you better/in order to get a better
understanding about your general health
I need to ask you few questions regarding your general health
SOCIAL HISTORY: Few questions about your social life
Now I’m just going through everything to understand all you have told me – Is there anything I’ve
missed
End of discussion – SUMMARY – Shall we go through all you have told me or talked about
PERSONAL – I need to ask you some questions about your sexual life / LMP / Recreational drug use
STRUCTURE OF MEDICINE STATIONS
P1 – Presenting Complaint (SOCRATES, ODIPARA – discussed above)

ICE
1) Do you have any idea regarding your condition
2) What are you hoping from us today?
3) What are your concerns?

DIFFERENTIAL DIAGNOSIS

P2 (a) Past History of Presenting Complaint

P2 (b) - Past Medical History

- Past Surgical History
- Past Hospital Admissions

P3 (DESSAR)
D – Diet
E – Exercise
S – Smoking
S – Stress
A – Alcohol
R – Recreational Drugs

MAFTOSA (discussed above)

EXAMINATION: - Vitals (Temp, Pulse, HR, Resp Rate)

- Specific (Chest, Abdomen, Any other)

Convey your findings on examination to the patient

MANAGEMENT:
1) Admission/observe/referral/send home
2) Inform Seniors
3) Investigations
4) Symptomatic Treatment + Lifestyle modifications (Use the word I here)
5) Specialist referral + Specific Rx (Use the word “we” here)
6) Safety netting
7) Follow-up
STRUCTURE OF PAEDS STATIONS
P1 - SOCRATES/ODIPARA (Presenting complaints)
a) Which symptom makes you worry more?
- then ask one by one
b) History & Concerns - Child
(IPS for 2 persons) - Mother - How are you coping with this situation?
- What are your concerns?
- How you are handling with this situation?
c) Head to Toe Questions
d) BIRDDDD or BIRD4 - B (Birth History) - Before delivery
- Delivery (term, pre-term)
- After delivery (any hospital
admission)
- I (Immunization History)
- R (Red Book) - Any concern about red book?
- D (Developmental History) - Are you satisfied with height
and weight of your child?
- D (Diet History) - Is child feeding normally?
- Is child taking diet properly?
- D (Dehydration History) - Dry tongue, dry mouth
- Crying without tears?
- Sunken eyes?
- Same nappies as before?
- Is he playful?
- D (Danger History)

Developmental Milestones - Smile 1 month (3x1)

(check according to age) - Sit 6 months (3x2)
- Crawl 9 months (3x3)
- Walk 12 months (3x4)
- Talk 15 months (3x5)
- Dress 30 months (3x10)

MAFT - Medicine
- Allergy
- Family History
- Travel History - Any travel to other place?
- Anyone else with same history?

EXAMINATION (same as in medicine station)

MANAGEMENT (same as in medicine station)

STRUCTURE OF SURGERY STATIONS
P1 - Presenting Complaints
- DD
- ICE

Follow the patient - Pre-op complications

- Operative
- Post-op complications

P2a Did you have this condition before?

P2b - Past medical history

- Past surgical history - Any surgery before
- Any anaesthesia complication
- Any post op complication
- Past hospital admissions

P3 DESSA-R

MAFTOSA

FOLLOW-UP (If not done after P1) *Either follow the patient in P1 or after MAFTOSA

EXAMINATION: - Vitals
- Specific

ICE

MANAGEMENT: - 7 points as in medicine structure)

- RAMMS - Risk factors
- Advice
- Medicine
- Multi-disability
- Multidisciplinary team
- Safety netting
STRUCTURE OF OBSTETRICS/GYNAE STATIONS
P1 a) SOCRATES/ODIPARA
b) D/D
c) Risk factors and complications

P2a - Same condition in past

- Past history of presenting complaint

P2b - Past medical history

- Past surgical history

P3 DESSA-R + Sexual history

P4 - P (pregnancy)
- P (periods)
- P (pills)
- P (Pap smear)

MAFTOSA

Thank you very much for answering all these questions

EXAMINATION - Vitals
- Abdominal Exam
- Pelvic Exam - Per speculum exam - Take swab

MANAGEMENT (7 steps)
STRUCTURE OF PSYCHIATRIC STATIONS
MC FAMISHT - M (Mood)
- C (Cognition) - Name
- Age
- Address
- F4 - Family
- Friends
- Finances
- Forensics
-A - Alcohol & Other drugs
- Allergy
-M - Medical condition
- Medication
- Mental health
- I (Insight & Impact)
- S (Suicide)
- H (Hallucination) - Olfactory
- Audible
- Visual
- Tactile
-T - Thought insertion
- Thought withdrawal
- Thought broadcast

CAGE TWD C (CUTTING) - Is this the first time you want to cut down
- Have you ever tried to cut it down before
- Did you seek medical advice
A (ANNOYED) - Do you think people criticize your drinking habit
- Are you annoyed?
G (GUILTY) - Do you feel guilty for your addiction?
E (EYE OPENER) - Do you drink alcohol first thing in morning?
T (TOLERANCE) - Do you have to increase the amount of alcohol to get the same
effect?
W (WITHDRAWAL) - How do you feel when you don’t drink?
D (DEPENDENCY) - Can you do your daily activities without taking these?
- Are you able to do work without taking alcohol
STRUCTURE OF COUNSELLING STATIONS
ICE - Start with ICE
- Give more importance to “C”
- Tell the patient your concern is very valid but is it okay if I could ask you a couple of
questions regarding your health so I will be able to be in a better position to address your
concerns.

HISTORY - Past 10 Qs
- Present 10 Qs
- Future (in few cases in history)

P2a
(same as in medicine structure)

P2a
(same as in medicine structure)

P3
(same as in medicine structure)

MAFTOSA

EXAMINATION
P2a (same as in medicine structure)

MANAGEMENT
Same as in surgery structure
MISCELLANEOUS STATIONS
UROLOGY HISTORY

Presents with – PAIN

– INFECTION
– POOR STREAM

PAIN
-SOCRATES

INFECTION
-Any pain on passing urine? -Burning sensation on passing urine
-Frequency
-Lower abdominal pain
-Temperature
-Previous treatment of UTI
-Previous history of kidney stones

STREAM
-Do you notice when you pass urine, you are not able to pass straight away - Hesitancy
-Poor stream – stream not like before/reduced
-Dribbling – Any dribbling after urine
-Urgency – Do you need to rush to the toilet
-Incomplete voiding – feeling it is not empty
-Nocturia – Do you need to wake up?

OBSTETRIC HISTORY
-Pregnancy that reaches 24 weeks (viable age) = PARA (still birth or live birth)
-Number of pregnancies = GRAVIDA - Whether abortions, miscarriages, etc

HISTORY IN A PREGNANT WOMAN

-Gestational age
-No of children
-No of pregnancies in the past
-Any previous abortion – Surgical/medical treatment
– Age
-Miscarriage – Age
– Self limiting
– Medical/surgical treatment
-Continued Obstetric History
- 1st ANC booking
 - Booking BP
- Infection screen ‘syphilis, HIV, rubella
-Hep B & C – routine
-Blood group, FBC
-Attending all ANC follow ups
-Dating USS in 12 weeks
-Problems in current
-Vomiting, BP, high BP, sugar, bleeding
-Family history of BP, BS
-Problems in previous pregnancies

RHEUMATOLOGY HISTORY
1) PAIN, e.g. joint pain
2) STIFFNESS IN THE JOINT
3) SWELLING IN THE JOINT

PAIN – SOCRATES

STIFFNESS
-What time is the stiffness worse - morning
- evening
-Does exercise make it worse or better
-Assessment with joint points - Large or small
- Proximal or distal
-Assessment with joint swelling - Symmetrical
- Nonsymmetrical

SWELLING
-Where is the swelling? - On the joint?
- Extensor surface?
- Swelling anywhere else?
-Warm to touch
-Redness of the joint
-Any pain?
-Any rash?
-Any stiffness?