Table of Contents
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
