Suggested approach to common acute presentations

Acutely Unwell Patients > ABCDE

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

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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

Key differentials
- 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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