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
- 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)
- 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
- 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. 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
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
- Headache
- Chest pain
- Shortness of breath
- Shortness of breath II
- Abdominal pain
- Abdominal pain II
- Find more stations here