Acute presentation assessment

Find examples of the specifics to assessing common acute presentations here.

Introduction

• Wash hands
• Introduce self
• Ask Patient’s name and DOB
• Explain you want to ask them some questions and examine them
• If they are critically ill, use an ABCDE approach
• Give oxygen, fluids, analgesia as soon as you realise the patient needs them (‘ask a nurse’ to do it while you continue assessing)

Focussed history

• Presenting complaint
• History of presenting complaint
  • Explore symptoms, e.g. SOCRATES for pain (see history notes on exploring symptoms)
  • Important parts of relevant systems reviews to include or exclude differential diagnoses (see history notes on systems review)
• PMHx (focus on PMHx relevant to problem)
• DHx + allergies
• FHx: if relevant to PC (e.g. family cardiovascular history if patient presents with chest pain)
• SHx: smoking and alcohol

Check observations

Determine the patient’s observations:

• HR and BP
• Respiratory rate and O₂ saturations
• Temperature

Focussed examination

• Quick general exam
  • Surroundings: drips, medications, catheters, monitoring
  • General inspection: well/unwell, breathing pattern, in pain, pale, sweaty/clammy
  • Hands: shut down, tremor, capillary refill
  • Pulse: rate, rhythm, volume (central and peripheral) 
  • Eyes: pallor, jaundice
  • Mouth: dry mucus membranes, cyanosis
• Perform the appropriate focussed system examination – see examples here

Investigations

• BOXES – choose relevant ones to include or exclude differentials
  • Bloods + cannulate (mark as urgent): e.g. VBG and venous bloods (FBC, CRP, U&Es, LFTs ± amylase, G&S, INR), blood culture, ABG, capillary glucose 
  • Orifice tests: e.g. urine dip, urine βHCG, sputum culture, stool culture
  • X-rays/imaging: e.g. CXR, abdominal X-ray
  • ECG
  • Special tests: depending on likely cause (see here)

Management  

Acute management tetrad:

• Oxygen – if low sats (e.g. 15L via non-rebreather mask if not at risk of hypercapnic respiratory failure)
• Fluids – if hypotensive or dehydrated (e.g. bolus 500ml 0.9% saline / Hartmann’s solution if no heart failure)
• Analgesia – e.g. up to 10mg morphine IV titrated slowly to pain if severe ± antiemetic ± antipyretic
• Disease-specific treatments – depends on cause (see here)

NB: use ABCDE approach if critically unwell.

Finally

• Check for patient concerns and explain what’s going on
• Document in notes
• Chase investigation results (and change plan as necessary)
• Discuss with seniors if required and refer to relevant team if necessary 

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Test yourself

You undertake an assessment on a 34 year old female with right iliac fossa pain. Which investigations would you request?

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You suspect a patient has appendicitis. What is your initial management?

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You assess a patient with breathlessness and pleuritic chest pain. You suspect a pulmonary embolism. Which initial investigations would you request? What is your initial management?

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Try some acute assessment OSCE stations

1. Headache
2. Chest pain
3. Shortness of breath
4. Shortness of breath II
5. Abdominal pain
6. Abdominal pain II
7. Find more stations here