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Suggested approach to common acute presentations

The acute presentation assessment is outlined here. Below are some examples to demonstrate how we suggest you assess some common acute presentations.

Why don’t you test yourself by thinking what what you would do before expanding the boxes?

Shortness of breath

Key differentials

  • Life-threatening
    • PE
    • Pneumothorax
    • Asthma/COPD
    • Pneumonia
    • Acute LVF
    • ACS

Focussed history

  • Exploring
    • When did it start? How did it come on?
    • Getting worse?
    • Exercise tolerance (current vs. normal)
    • Orthopnoea, paroxysmal nocturnal dyspnoea
  • Systems reviews (important parts)
    • General: how patient feels, fever
    • Cardiorespiratory: chest pain, wheeze, cough, sputum, leg swelling
  • PMHx
    • Happened before? Other medical conditions
    • If asthma/COPD: baseline and severity (including home nebs/oxygen), exacerbation history (spectrum: home → GP → ward → non-invasive ventilation → ICU/intubated), normal peak flow
    • Recent surgery
  • DHx + allergies
    • Remember inhaler compliance
  • SHx
    • Smoking, alcohol, long-haul travel

Focussed examination

  • Quick general exam
    • Surroundings: drips, medications, 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
    • Mouth: dry mucus membranes, cyanosis
  • Cardiorespiratory
    • Tracheal deviation and JVP
    • Inspect chest
    • Expansion, apex, heaves
    • Percuss
    • Auscultate heart and lungs
    • Legs (swelling/tenderness/ oedema)
    • Peak flow if asthmatic

Investigations

  • Bloods
    • FBC, CRP, U&Es
    • D-dimer (to exclude PE if Wells score low)
    • B-type natriuretic peptide (if suspect heart failure)
    • Blood cultures if pyrexial
    • ABG
  • Orifice tests
    • Sputum culture
  • X-rays/imaging
    • CXR
    • CTPA (if PE suspected)
  • ECG

Chest pain

Key differentials

  • Life-threatening
    • ACS
    • PE
    • Aortic dissection
    • Pneumothorax
    • Pneumonia

Focussed history

  • Exploring
    • SOCRATES
  • Systems reviews (important parts)
    • General: how patient feels, fever, clammy
    • Cardiorespiratory: SOB, wheeze, cough, sputum, leg swelling
  • PMHx
    • Happened before? Other medical conditions
    • Cardiovascular risk factors
  • DHx + allergies
    • Including cardiovascular medications
  • FHx
    • Cardiovascular events in close family
  • SHx
    • Smoking, alcohol, long-haul travel

Focussed examination

  • Quick general exam
    • Surroundings: drips, medications, 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
    • Mouth: dry mucus membranes, cyanosis
  • Cardiorespiratory
    • Tracheal deviation and JVP
    • Inspect chest
    • Expansion, apex, heaves
    • Percuss
    • Auscultate heart and lungs
    • Legs (swelling/tenderness/ oedema)

Investigations

  • Bloods
    • FBC, CRP, U&Es
    • Troponin testing
  • X-rays/imaging
    • CXR
    • CTPA (if PE suspected)
    • CT angio (if aortic dissection needs to be excluded)
  • ECG

Abdominal pain

Key differentials

  • Life-threatening
    • Peritonitis
    • AAA
    • Ischaemic bowel
    • Medical causes (DKA, pneumonia, MI, Addisonian crisis)
  • Upper abdomen
    • Hepatitis, cholecystitis, peptic ulcer, pancreatitis
  • Lower abdomen
    • GI (appendicitis, IBD, diverticulitis)
    • Urinary (UTI/pyelonephritis, renal calculi)
    • Gynaecological (ectopic, ovarian torsion, PID)

Focussed history

  • Exploring
    • SOCRATES
  • Systems reviews (important parts)
    • General: how patient feels, fever
    • Gastro: nausea and vomiting, bowel habit, blood/melaena, weight loss
    • Urological: dysuria, urinary frequency
    • Gynaecological: last menstrual period, PV discharge, contraception, chance of pregnancy
  • PMHx
    • Happened before? Other medical conditions
  • DHx + allergies
    • Including relevant medications
  • SHx
    • Smoking, alcohol

Focussed examination

  • Quick general exam
    • Surroundings: drips, medications, catheters, monitoring
    • General inspection: well/unwell, 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
  • Abdominal
    • Inspect (movement with respiration, Grey Turner’s/ Cullen’s signs, scars)
    • Guarding and rebound tenderness
    • Murphy’s sign, Rovsing’s sign
    • Quickly palpate liver, spleen, kidneys and for AAA
    • Palpate for hernias
    • Percussion tenderness
    • Bowel sounds
    • Also examine external genitalia and perform a digital rectal exam if indicated

Investigations

  • Bloods
    • FBC, CRP, U&Es
    • LFTs, amylase
    • INR, G&S
    • Capillary glucose
    • VBG (lactic acidosis in ischaemic bowel)
  • Orifice tests
    • Urine dip
    • Urine βHCG
  • X-rays/imaging
    • Erect CXR
    • AXR (if suspect bowel obstruction)
    • FAST scan (for AAA)
    • USS/CT abdomen
  • ECG

Headache

Key differentials

  • Life-threatening
    • Subarachnoid haemorrhage
    • Meningoencephalitis
    • SOL
    • Giant cell arteritis
    • Pre-eclampsia
  • Common
    • Migraine, tension headache, cluster headache, sinusitis
  • Rarer but still important
    • Venous sinus thrombosis, carotid dissection, hypertensive encephalopathy, hypercapnia, glaucoma, pituitary apoplexy, idiopathic intracranial hypertension

Focussed history

  • Exploring
    • SOCRATES
    • Meningism symptoms: rash, fever, neck stiffness, photophobia
    • Giant cell arteritis symptoms: visual problems, jaw claudication, scalp tenderness
    • Glaucoma symptoms: visual problems, red eyes, halos around lights
  • Systems reviews (important parts)
    • General: how patient feels, fever, rash
    • Neurological: fits/falls/LOC, limb weakness, altered sensations, vision
  • PMHx
    • Happened before? Other medical conditions
  • DHx + allergies
    • Including anticoagulants, steroids, analgesia
  • FHx
    • e.g. for berry aneurysms
  • SHx
    • Smoking, alcohol, travel

Focussed examination

  • Blood pressure, temperature
  • GCS, signs of photophobia, rash
  • Eyes: pupils, redness, acuity, fields, fundoscopy to look for papilloedema (↑intracranial pressure) or haemorrhages
  • Feel sinuses and temporal arteries for pulsation/tenderness
  • Neck stiffness: passively turn head side to side and touch ears to shoulder
  • Brudzinski’s sign (passive flexion of neck causes involuntary flexion of knee and hip)
  • Kernig’s sign (pain on passive knee extension with hip fully flexed)
  • Motor neuro exam: tone, power, reflexes
  • Cranial nerves exam

Investigations

  • Bloods
    • FBC, CRP, U&Es
    • ESR (if >55 years)
    • Blood cultures if pyrexial
    • Meningococcal PCR
  • X-rays/imaging
    • CT head
  • Special tests
    • Lumbar puncture

Test your knowledge

You assess a patient with a sudden onset severe headache, that reached its peak within 60 seconds. What are you concerned about and which investigations would you request?

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A patient presents with tearing chest pain, radiating from the front of their chest to the back. What are you concerned about? Are there any clinical signs that may support the diagnosis? Which investigation would be definitive?

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You assess a diabetic patient with abdominal pain. You suspect DKA. What are the diagnostic criteria? What is the 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
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