Adult

Presenting Complaint

Ask:

  • Who called for help?
  • What are your immediate concerns?

History of Presenting Complaint

  • First - Allow the patient to talk freely
  • Then ask some specifics - below are some common situations

Pain

Ask:

Site:

  • With one finger, can you point to where it started?
  • Physically inspect the site of pain

Onset:

  • When did it start?
  • What were you doing when it first started?

Character:

  • If you could put the pain or discomfort into words, how would you describe it to me?

Radiates:

  • Does it go anywhere else on your body?

Associated symptoms:

  • Since it started have you noticed any other symptoms or changes in your body?

Time/duration:

  • Is it constant or does it come in waves?

Exacerbating/relieving factors:

  • Does anything you do relieve the pain/discomfort or make it worse?

Score:

  • How would you score the pain when it first started (0 no pain - 10 extreme)?
  • What would you score it now?
  • Has this ever happened to you before?
  • Have you taken anything for it?

-- Stop, Think & Ask yourself --

  • DO YOU NEED TO ACT UPON WHAT WAS SAID
  • ARE YOU CONCERNED?

SOB/DIB

Ask:

  • When did it first start?
  • Did it come on suddenly or gradually?
  • What were you doing when it first started (rested/walking)?
  • Any chest pain/discomfort before or after the event?
  • Any recent sore throats, runny nose or coughs?

Fall

Ask:

  • When did you fall?
  • Can you recall how it happened?
  • Clarify the following:

  • Was it from sitting or standing height?
  • Did you feel dizziness before the fall?
  • Did you lose any consciousness?
  • Any chest pains?
  • Did anyone witness the fall?
  • Where did you fall here or somewhere else?
  • Were you able to brace yourself or control the fall?
  • Have you mobile or immobile on the floor?
  • Any new pain or discomfort since falling?
  • Have you tried to get up?
  • How did you call for help?
  • Who found you?
  • Any new pain?
  • Total time on the floor?
  • When did you last fall?

Consider:

  • Total time on the floor
  • Items moved or knocked over
  • Mechanism of Injury

Pregnancy

Ask:

  • How many weeks gestation are you?
  • When is your Estimated Delivery Date (EDD)?
  • Are you expecting a single child, twins or triplets?
  • Are you under midwife or consultant care?
  • At which hospital?
  • Any complications or past miscarriage?
  • What is your birth plan (VB/Cesarean)?
  • Is this your 1st child?
  • Any PV bleeding (how many pads have you gone through)?
  • When did you last feel baby move?
  • Are you in any pain (use SOCRATES)?
  • Do you have the urge to push down?
  • Have your waters broken (Spontaneous Rupture Of Membranes -SROM)?
  • Any meconium seen?
  • Any crowing?
  • Do have your medical/Maternity notes?

Rash

Ask:

  • When did it first start?
  • Where did you first notice the rash?
  • Has it spread anywhere else?
  • Has it always looked like this or has it changed (if so in what way)?
  • Have you experienced any other symptoms like fevers, pain, discomfort, itching or anything unusual?
  • Has it continuing to spread or has it stabilised, or even reduced?
  • Before it started does anything stand out that could have caused this, for example was you unwell, eaten or applied something to the skin?
  • Have you been in contact with anyone else with this rash?

Inspect & assess:

  • Glass tumbler test + or -
  • Is it raised?
  • Warm to touch?
  • Colour?

Mental health

Ask:

  • Who called for help?
  • What did they notice?
  • Any triggers relating to the presenting complaint?
  • Note - You must make sure that there are no physical concerns for example low BM, hypoxia, infection makers, low BP or anything else that can affect someone's state of mind.

  • For further assessment, see below - On examination below - mental wellbeing

Generally unwell

Ask:

  • When did the symptoms first start?
  • What other symptoms have you been experiencing?
  • What particularly changed for you seek help?
  • When did you last see a Doctor

Physical assessment

Quick Assessment- At all stages assess for DCAPBLS

  • Head: Skull injury, Battle sign, Racoon eyes, Conjunctive polar, Pupils, Sclera colour, Oral cavity/Tounge presentation, FAST test
  • Neck: C-spine pain, Range of Movement, JVP
  • Chest: FLAPS-TWELVE, Lung sounds, Heart sounds
  • Upper limbs: Tone & Strength, Radial pulses, Finger clubbing/Spliters
  • Abdo: Inspect, Palpate, Percuss, Ausculate - Presenation, Hardmass, Gurading, Pulsatile mass, Bowel sounds
  • Lower limbs: Any ROM, Calf/Limb swelling
  • MSK/Skin: Any overall deformities, contusions, abrasions, punctures/penetrations, burns, tenderness, lacerations and swelling/surgical/self-harm marks
  • Dermatomes: Any loss in sensory sensation
  • Vitals: GCS, HR, BP, ECG, Temp, BM, NEWS2

Allergies

Ask:

  • Are you allergic to anything (If YES - What happens)?

Medication

Ask:

  • Do you take medication on a daily basis & if so, what for?
  • Are you taking them as required?
  • Any recent changes?
  • Have you taken any medication in the last 6 hours?

Medical Conditions

Ask:

  • Any past medical conditions?
  • Has this ever happened before?
  • When did you last see a Doctor (if recent, what for)?
  • Are you under any medical investigations/tests?
  • Any family history of this?
  • Any special needs/requirements?

Tip:If the patient states they have no medical conditions, but you suspect there might be, reconfirm using a head-to-toe stepwise approach, for example;

"Can I just reconfirm have you had any?

  • Head: Any strokes? Seizures? Mental health? Anxiety? Neurological conditions to do with the brain?
  • Neck: Thyroid problems?
  • Chest: Lung problems? Breathing problems? Asthma? COPD?
  • Heart: Heart conditions? Heart attacks? Arrhythmias? High blood pressure/cholesterol? Blood conditions?
  • Abdo: Kidney problems? Digestive problems? Diabetes?
  • Pelvis: Reproductive or urinary problems?
  • Skeletal: Bone conditions? Osteoporosis? Arthritis?
  • Cancers

Surgical history

Ask:

  • Any surgery or body organs removed?

Review of systems

State:

  • Based on the last 14 days;

Pain

  • Any new pain or discomfort anywhere on your body, that I need to be aware of?

Verbal assessment:

Site:

  • With one finger, can you point to where it started?
  • Physically inspect the site of pain

Onset:

  • When did it start?
  • What were you doing when it started?

Character:

  • If you could put the pain or discomfort into words, how would you describe to me (Dull, Sharp, Ripping, Crushing, Constricting pain/discomfort)?

Radiates:

  • Does it go anywhere else on your body?

Associated symptoms:

  • Since it started have you noticed any symptoms or changes in your body?

Time/duration:

  • Is it constant or does come in waves?

Exacerbating/relieving factors:

  • Does anything you do relieve the pain/discomfort or make it worse?

Score:

  • How would you score the pain when it started ( 0 no pain - 10 extreme)
  • What would you score the pain now?
  • Has this ever happened to you before?
  • Have you taken anything for it?

Nervous system

A&P Video

Verbal assessment:

  • Can you confirm what year/month & day it is? (A&OX3)?
  • Any headaches?
  • Have you blacked out (LOC)?
  • Any observed confusion?
  • Can you see me clearly?
  • Any visual disturbances?
  • Did you go dizzy/light headed with the events?
  • Can you read written text (is speech normal/slurred)?
  • Can you hear me clearly?
  • Any neck discomfort?
  • Any pins or needles?
  • Any numbness?
  • Any seizure activity?

Physical assessment:

  • Glasgow Coma Score
  • Pupils equal and reactive to light pearl?
  • Pupil size?
  • Photophobic?
  • Any nystagmus?
  • Hand-eye coordination?
  • Peripheral vision?
  • Face Symmetrical any droop?
  • Dermatomes intact?
  • Shoulder / Arms / legs equal tone & strength? Any weakness? Ataxia? Clench buttocks?
  • Tongue deviation?
  • Any seizure activity described (How many? Duration? Aura? Type? Febrile? Tonic/Clonic? Decorticate /Decerebrate posturing)?
  • Cerebral irritated/Combative/Postictal?
  • Any Neurological deficit found (Onset)?
  • Any Mental Health Concerns?

CPD links:

Respiratory system

A&P Video

Verbal assessment:

  • Any shortness of breath at rest?
  • When walking around, any shortness of breath?
  • Any difficulty in breathing?
  • If you take a deep breath in, do you feel any restrictions?
  • Any recent sore throat, runny nose or sneezing?
  • Have you been coughing or bring anything up?
  • Do you smoke (if so, how many a day)?

Physical assessment:

  • Resp rate?
  • Regular/IRR?
  • Work of breathing?
  • Inspiratory/Expiratory (I:E) ratio 2:1?
  • Sp02% on room air?
  • Sp02% post stress test?
  • Oral cavity/Neck: Any swellings?
  • Vocal sounds?
  • Tracheal deviation?
  • Wounds?
  • Emphysema (surgical)?
  • Laryngeal crepitus / injury
  • Veins distended (neck)
  • Finger clubbing?
  • Tremors?
  • Central / Peripheral cyanosis?
  • 6 P's of dysonea

Palpate:

  • Un/Equal chest expansion?

Percuss:

  • Any hyper/hyporesonance?

Auscultate:

  • Any unusual sounds (Rhonchi, Wheeze, Pleuritic rub, Crackles (Heart fail) Reduced sounds (Silent chest) Lung sounds library?
  • Bilaterally air entry?

CPD links:

Cardiovascular system

A&P Video

Verbal assessment:

  • Any blood loss (where from & amount)?
  • Any chest pains or discomfort?
  • Have you felt any palpitations or thuds in your chest?
  • Any blood or clotting conditions?
  • Have you notice any swellings to your wrists, calves, ankles feet?

Physical assessment:

ECG:

  • HR?
  • Reg/IRR?
  • Waves present: P-QRS-T?
  • PR/QRS/QT intervals (WNR)?
  • ECG Rhythm (A to Z ECG library)?
  • 12 lead: Any STe / depression / ischemic changes?
  • Conjunctival pallor?
  • Jugular vein raised?
  • Any splinter haemorrhage?

Palpate:

  • Radial pulse (PR) rate/Reg & equal?
  • Any Radio-radial delay?
  • BP L/R Arm & Standing?
  • CRT < 2sec's
  • Sacral / ankle pitting?
  • Swollen calf (DVT calculator)?
  • Limbs: Warm / Cold?

Auscultate:

Think

  • Any ACS symptoms?

CPD links:

ECG stepwise guide

3 lead quiz questions

What's is the rhythm quiz

12 lead quiz questions

Immune system

A&P Video

Verbal assessment:

  • Any resent known infections?
  • Any fevers?
  • Feeling cold?
  • Have you taken antibiotics within the last 30 days?
  • Any known immune conditions for example chemo?
  • Has anyone else at home been unwell recently?
  • Are your Inoculations/Vaccinations up to date?

Physical assessment:

  • Any organic concerns?
  • Any Sepsis markers?
    • Immunocompromised (On steroids, Chemo in last 6 weeks)?
    • NEWS2
    • Any organic / biological concerns?
  • Digestive system

    A&P Video

    Verbal assessment:

    • When did you last eat?
    • How is your appetite?
    • Any difficulty swallowing?
    • Do you feel bloated?
    • Any nausea or vomiting?
    • If you look at your abdomen, does it look normal to you?
    • Any drastic diet changes?
    • When did you last open your bowels?
    • Any diarrhea?
    • Consipation?
    • Any drastic weight loss or gain?

    Physical assessment:

    Inspect:

    • Liver or spleen injuries?
    • Cullens signs?
    • Grey Turner's signs?

    Palpate:

    • Any Guarding?
    • Distension?
    • Rebound/Tenderness/pain?
    • Rigidity?
    • Swelling?
    • Hard / Pulsatile mass?
    • Hernia's?
    • Psoas +/-?
    • Murphy’s + OR -?

    Percuss:

    • Ascites?

    Auscultate:

    • Bowel sounds?

    Other:

    • Patient approx. weight?

    CPD links:

    Endocrine system

    A&P Video

    Verbal assessment:

    • How would you describe your energy levels: (Lethargic/fatigued/weak/tired)?
    • If diabetic - What is your normal blood glucose level?

    Physical assessment:

    • Blood glucose level (BM)

    Urinary system

    A&P Video

    Verbal assessment:

    • Are you drinking 2 litres or more of non-alcohol of fluids a day?
    • Any alcohol consumed within the last 12hrs?
    • How much alcohol do you consume within a week?
    • When did you last pass urine?
    • Are you urinating more or less?
    • Any pains or smells when passing urine?
    • Did you notice what colour it was?

    Physical assessment:

    Reproductive system

    Female

    Ask:

    • When was your last menstrual cycle?
    • Was it normal?
    • Is there any chance you could be pregnant?

    Male

    Ask:

    • Any recent trauma?
    • Raised testicular?
    • Erectile dysfunction?
    • Any lumps found?
    • Changes in colour?

    Skin

    A&P Video

    Verbal assessment:

    • How does the patient look to others?
    • Any clamminess?
    • Any cyanosis?
    • Any rashes?
    • Open wounds?
    • Any bruising?
    • Any lumps?
    • Any scars (surgical or self-harm)?

    Physical assessment:

    • CRT under 2 sec's?
    • Contusions?
    • Abrasions?
    • Pressure sores or penetrating injuries?
    • Bruising or burns?
    • Lacerations?
    • Swellings?
    • Warm area?
    • Hives?
    • Lumps?

    MSK system

    A&P Video

    Verbal assessment:

    • What is your mobility normally like?
    • Are you independent or do you use mobility aids?
    • Have you fallen over recently and not told anyone about it?
    • Any recent trauma?
    • Can you stand for me?
    • Can you walk room-to-room for me?
    • Is that your normal walk (any grimacing)?
    • Any new reduced range of movement?

    Physical assessment:

    Head:

    • Bogie mass?
    • Battle/Raccoon eyes?
    • Any seen CSF?
    • Open or suspected skull #?
    • Any head injury within the last 3 months?

    Spine:

    • C1 to L5: Pain or Tenderness?
    • Safe Rotation, Flexion, Extension & Lateral flexion of head?
    • Any significant distracting injury?

    Thoracic/upper limbs:

    • Raise arms above head, behind back and in a 360 circular motion?
    • Clavicle fracture?
    • Fractured ribs?
    • Flail chest/segments?
    • Normal flexion and extension?
    • Wrist & Hand Grip?

    Lower back:

    • Pain or tenderness?

    Pelvis/Hip:

    • Symmetrical?
    • Tenderness?

    Lower limbs:

    • Shorting/rotation?
    • Any new reduced range of movement?
    • Any deformities?
    • Ottawa ankle rule

    Mental Well-being

    Ask and Assess:

    • How is your mental well-being?
    • Sleeping well?
    • Any drastic lifestyle changes?
    • Are you under any stress?

    Appearance:

    Mannerism:

    Behaviour:

    • Who noticed the change in behaviour?
    • When did it change?
    • What has changed?
    • Acute behaviour disturbances?
    • Are they stressed, Why?
    • Withdrawn?
    • Delusion?
    • Hallucination?
    • Manic/Mania signs?
    • Controlled by external forces?
    • Emotionally Un/Stable?
    • Angry, why?
    • Able to focus?
    • Non/Cooperating manor?
    • Have rational thinking?
    • Un/Able to self-regulate behaviour?

    Speech/Verbal:

    • Able to hold a conversation?
    • Speech speed - slow/normal/fast
    • Easy two-way flow of conversation?
    • Guarded / plans what to say?
    • Able to communicate thoughts?

    Self-harm/Suicidal:

    • Do they have any self-harm or suicidal thoughts?
    • Have they self-harmed (How)?
    • What was their intentions?
    • Do they what to hurt others?

    Coping mechanisms:

    • Do they have any coping mechanisms?
    • Do they talk to anyone about how they are feeling/mental health?
    • Support network (friends/family)?
    • Hobbies?

    Home/Family life:

    • Who do they live with?
    • What is the home environment like?
    • Clutter scale score?
    • Relationship status - married, single, dating?
    • Any departments or children (think ACE's)?

    Social life:

    • Friendships/Support network?
    • Alcohol intake?
    • Recreational drugs?

    Work:

    • Employed?
    • Retired (What do/did you do for work)?
    • Goals/Ambitions?

    Other:

    • Any triggers?
    • Goals/Ambitions?
    • Any formal mental health diagnosis?
    • Known to any mental health teams?
    • Any alcohol or recreational drugs consumed?
    • Taking mental health medication as required?
    • Any signs of radicalisation (PREVET)?
    • Money/Income problems?
    • Any undiagnosed mental health symptoms?
    • Safeguarding / welfare concerns?
    • Does the patient have mental capacity?

    Other

  • Does anyone in your family have similar symptoms or significant medical conditions?
  • When did you last see a Dr or health care professional?
  • Are you under any health related investigations?
  • Conclude by asking:

    • I've asked you lots of questions. Is there anything else I should be aware of that I haven't covered?

    Bio-social

    Under 18 yrs

    • Can I confirm do you live here or somewhere else?
    • Who do you live with?
    • Are you in education (at which school)? & are you attending as required?
    • Are you a carer to anyone Or is anyone dependant on you?
    • Are you known to social services?
    • Who is your next of kin?

    Adult

    • Can you confirm your home address?
    • Who do you live with?
    • Is anyone dependent on you?
    • Are you in work, if so what do you do?
    • Is there a care page in place - if so how many times a day?
    • Who is your next of kin?

    Patient I.C.E

    Ask:

    • Ideas: What are your thoughts regarding the (presenting complaint)?

    • Concerns: What are you concerned about now?

    • Expectations: Moving forward from here how do you think I can help you today(if not obvious)?



    Impressions

    This is where you draw upon your education, training, questioning, physical and verbal assessment and other sources.

    Discuss:

    • Your thoughts about the presenting complaint & findings with the patient.

    Example:

    • Central chest pain, CVS related,? ACS
    • Pyrexia, immune response to ? Resp infection
    • Tachycardia, ? Pain related to MSK injury
    • It is whatever your impressions of the PC is

    Clinical concerns

    If any - discuss your concerns with the patient.

    • What have you identified/have concerns about?
    • Health status Deteriorating/Stable/Improving/Back to normal
    • Differential diagnosis (DDX)?
    • Risk factors?
    • NICE guidelines
    • Local guidelines
    • If none, explain and document none.

    Safeguarding

    Think & observe:

    Document:

    • Any findings or concerns
    • Who else did you inform?
    • If none found document: Safeguarding considered, none found

    Mental capacity

    Mental capacity is a continuous patient assessment during your care. If concerned about their mental capacity you can use CURE as an initial informal assessment tool:

    • Communicate - Can you communicate with the patient (face-to-face, via 3rd party)?

    • Understand - Can the patient understand your impression & clinical concerns?

    • Retain & recall - Can the patient retain and recall your impressions & concerns?

    • Explanation - Can they provide you with a valid explanation of why they are declining aid/treatment without external pressure?

    ---

    If concerned YOU MUST:

    • Use formal local forms to assess mental capacity. For more information read NHS assessing mental capacity Click here

    Plan

    Conclude, document & create a plan of action

    • Reassure
    • Treat the PC with
    • Reassess
    • Discuss on examination/impressions & clinical concerns and patient ICE
    • Implement plan / pathways

    Handover/Pre-alert

    Phone call to HCP

    Introduce yourself:

    • Name
    • Skill grade

    Reason for the call (examples):

    • Discuss your concerns/findings
    • Unable to rule out anything sinister
    • Seeking a advise
    • NEWS > 3
    • Pt declining ED

    Clinical assessment:

    • PC
    • HPC
    • OA
    • PS
    • PMH
    • PSH
    • Allergies
    • DHx
    • On examination (review of systems)
    • Background
    • Impressions
    • Clinical concerns
    • Patient own words
    • Any safeguarding
    • Plan

    A&E Telephone pre-alert

    • Age/gender
    • Time of incident
    • Mechanism
    • Injury
    • Signs and Symptoms / Ob's
    • Treatment given & Time of arrival

    A&E Medical handover

    • Age
    • Time of onset
    • Medical complaint/history
    • Investigations (brief findings)
    • vital Signs (significant changes)
    • Treatment

    Background:

    • Allergies
    • PMH
    • DHx
    • Any safeguarding concerns

    Pre-alert Trauma H/O

    Introduction:

    • Your name
    • Clinical skill grade

    Pre-hospital trauma algorithm:

    • Any immediate concerns to CABCD

    ATMIST:

    • Age/gender/Pt name
    • Time of incident
    • Mechanism
    • Injury
    • Signs and Symptoms / Ob's
    • Treatment given

    Background:

    • PMH
    • Allergies
    • DHx

    Ask:

    • Any other questions?

    CPD Links

    Click here