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Suggested approach to common acute presentations

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
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