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
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?
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