Chapter 1. Initial assessment and emergency management
General history and examination 1
Assessment of the acutely ill patient 8
Cardiac arrest management 11
GENERAL HISTORY AND EXAMINATION
History taking
All clinicians use the same basic history taking template; however, flexibility is essential: be prepared to modify your approach depending on the clinical situation, the patient’s concerns or fears and their level of education and understanding.
History of the presenting complaint
This is the most conversational component of the medical history and it is relatively easy to lose focus or drift off into unrelated areas. Therefore, you need to structure the interview in a way that allows you to extract the relevant information, while remaining relaxed and polite. Never lose your temper with a so-called bad historian; good history takers can get the important points of the story from any patient. Use the following routine:
• correctly identify your patient, checking their name, address, date of birth and who referred them
• start with ‘open’ questions like ‘What has happened over the last few days?’ or ‘When did you last feel well?’
• listen during this first part of the consultation and let the patient talk
• form a differential diagnosis based upon the patient’s original description
• during the next part of the history, use ‘closed’ or direct questions to focus upon the important points and narrow your list of differential diagnoses based on associated features, speed of onset, duration, previous episodes, etc.
• the duration and speed of onset of the patient’s symptoms are particularly important, e.g. if a focal neurological defect develops over the course of a few minutes, this could be due to an acute vascular event; if it develops over a number of days there may be infection or demyelination, while a defect that develops over months could suggest an underlying tumour or subdural haemorrhage
• throughout the interview, be careful to use language that the patient will understand and avoid medical terminology
• finally, ask if the patient has any worries or concerns: fear and preconceptions often colour the interpretation of symptoms and are always important features of the history.
Systemic enquiry
A few further screening questions are sufficient to identify any areas worthy of additional focus:
• cardiovascular: chest pain, palpitations, breathlessness, orthopnoea, oedema
• respiratory: breathlessness, cough, sputum, haemoptysis, chest pain
• GI: abdominal pain or swelling, bowel habit and bleeding, vomiting, swallowing problems
• GU: dysuria, frequency, urgency, haematuria
• neurological symptoms: headache, weakness or altered sensation, fits, falls and funny turns, change vision, hearing or speech (see Table 1.1)
| Defect | Description | Cause |
|---|---|---|
| Receptive dysphasia | Difficulty in comprehension | Lesion in the dominant cerebellar hemisphere, commonly due to CVA in older patients or trauma in younger patients |
| Expressive dysphasia | Difficulty in word selection, may be isolated to the naming of objects (nominal) or people | |
| Dysarthria | Difficulty with the motor execution of speech | Slurred, staccato or scanning speech suggests cerebellar disease, e.g. MS. |
| Slurred speech and a weak voice suggests pseudobulbar palsy (e.g. due to CVA) |
• systemic: anorexia, weight loss, fever, night sweats, fatigue, sore or stiff joints, itch or rash.
Past medical history
Enquire about the following common illnesses, remembering that patients often employ informal labels (given in parentheses): asthma, COPD (bronchitis, emphysema), ischaemic heart disease (angina), myocardial infarction (heart attack), cardiac failure (fluid on the lung), diabetes mellitus, previous pulmonary TB, previous surgery, previous admissions especially to the intensive care unit (ICU), stroke, epilepsy (fits), hypertension (high blood pressure), hypercholesterolaemia, venous thromboembolism (thrombosis or clots), previous rheumatic fever or significant childhood illnesses.
Drug history
Accurate doses, including the timing of administration, are essential, especially for insulin regimes and patients taking warfarin, along with details of the specific formulation taken, e.g. the type of insulin and the device used; types of inhaler. If the patient is on a lot of medications, ask if they have an up-to-date repeat prescription with them.
Make specific note of drug allergies. Ask what the patient means by ‘allergy’: feeling sick or diarrhoea is often mislabelled as such.
In patients with lung disease, check if they are prescribed inhalers and that they know how to use them. Also ask if they are on long-term oxygen therapy (marker of disease severity). Check if the patient is on long-term oral theophylline or phenytoin; if so, you will need to measure a drug level before prescribing any additional IV treatment.
Family history
Enquire about conditions affecting family members, e.g. asthma, ischaemic heart disease, stroke, malignancy, diabetes.
Social history
This is an essential and often overlooked component of the history, especially in older or disabled patients. Accurately document home circumstances, e.g. living alone; independent at home but has social support; residential or nursing home resident. If the patient receives support at home, quantify this in terms of visits per day and the support provided. Ask if the patient has family nearby and if they see them.
Determine the patient’s functional capacity and whether they are able to perform the activities of daily living (ADLs), e.g. leaving the house, doing the shopping, housework or cooking. This information allows the setting of realistic discharge goals and is useful when considering treatment escalation or referral to intensive care. Ask about quality of life (QoL). Remember that this should be recorded as the patient describes it, not how you judge it; see ‘Performance status and quality of life’, p. 349.
Ask about recreational drug use. Document cigarette use by current and ex-smokers in pack-years and alcohol consumption in units per week:
• One pack-year equates to a pack of 20 cigarettes per day for a year: someone who has smoked 10-a-day for 50 years has a 25 pack-year history.
• One small glass of wine or one 25 mL measure of spirits is roughly equivalent to 1 unit; 1 pint of ordinary strength lager, beer or cider roughly equates to 2 units; recommended safe limits of alcohol per week for males and females are 21 and 28 units, respectively.
Psychiatric history
Formal psychiatric assessment should be performed in specialist units; however, psychiatric illnesses commonly present to other departments where they should be properly assessed and referred to psychiatry, as appropriate. A detailed history is essential and must include the following (in addition to a standard medical history):
• educational background, religion and occupation, as these may influence interview technique and general approach
• reason and source of referral (self-presentation indicates insight)
• history of the presenting complaint: enquire about the patient’s symptoms in their own words, including their effect upon normal function (e.g. work, family, relationships), date of onset, rate of progression and any precipitants identified by the patient
• previous treatments, including drugs, surgery and others, e.g. cognitive behavioural therapy, electro-convulsive therapy
• suicidal ideation.
Personal history should be taken in detail, including:
• childhood problems including parental separation and any history of abuse
• relationships and marital history
• work history, including current level of satisfaction at work and reasons for leaving previous jobs
• premorbid personality, e.g. anxious, obsessive, solitary
• cognitive assessment should be performed (cognitive dysfunction suggests organic rather than functional pathology)
• abbreviated mental test (AMT) score or the mini-mental state examination (MMSE); see Table 1.2 and Table 1.3, respectively
| Total score is recorded out of 10; a score <7 suggests cognitive dysfunction. | |
| Question | Score |
|---|---|
| What is your age? | 1 if correct |
| What is your date of birth? | 1 if complete |
| What year is it? | 1 for exact year |
| What time of day is it? | 1 if correct to nearest hour |
| What is this place? | 1 if correct, e.g. name of hospital or address |
| Recall a 3-line address (later in consultation) | 1 if correctly and completely recalled |
| Who is the current monarch? | 1 if correct |
| What year was World War I? | 1 for either 1914 or 1918 |
| Count backwards from 20 to 1 | 1 if no mistakes, or corrects without prompting |
| Can you identify these two people? | 1 for both names if known, or both jobs if not |
| aTotal score recorded out of 30; <23 suggests cognitive impairment. | ||
| Test | Questions | Maximum scorea |
|---|---|---|
| Time | Day, date, month, season, year | 5 |
| Place | County, country, town/city, building, floor | 5 |
| Registration | Name 3 objects, e.g. bed, table, book | 3 |
| Attention and concentration | Spell ‘world’ backwards or count out five serial 7s | 5 |
| Naming | Show 2 objects | 2 |
| Recall | Ask to recall the 3 objects registered earlier | 3 |
| Repeating | Repeat ‘no ifs, ands or buts’: only correct if word perfect | 1 |
| 3-stage task | Instruct the patient to (1) take this paper in your right hand, (2) fold it in half and (3) drop it on the floor | 3 |
| Reading | Write ‘close your eyes’; ask the patient to read and obey | 1 |
| Writing | Write a sentence: must be complete and grammatically correct | 1 |
| Construction | Draw interlocking pentagons | 1 |
• acute (delirium) and chronic (dementia) cognitive impairment should be distinguished by discussion with family members or social contacts.
Recording the history
When recording the history of the presenting complaint, include the main problem and mode of referral. This should be followed by a short paragraph that covers the relevant additional positive or negative points from the history with regard to this presenting problem, e.g. onset, duration, precipitating and relieving factors, previous similar events, as well as relevant admissions or outpatient attendances.
Examination
The guidance given here is necessarily brief. For more detail see Macleod’s Clinical Examination.
Consider whether you need a chaperone and ensure that the patient’s need for privacy is met. Ask for permission to examine them and check if there is any area that is sore to touch. Ensure that the patient is comfortable and in the correct body position for the system you aim to assess:
• cardiovascular and respiratory: 45° semi-recumbent
• abdominal: lying supine
• neurological: semi-recumbent position in bed or sitting in chair, depending on the particular examination performed.
Begin with a general examination, then follow the principles of inspection, palpation, percussion and auscultation as you work through the relevant body systems. Table 1.4 ( overleaf) highlights important signs to look for during your examination of each body system (the nervous system is addressed separately). Note that when palpating, you should start with the least painful side first and work slowly towards the site of worst pain.
| Cardiovascular | Respiratory | Abdomen | |
|---|---|---|---|
| Hands | Clubbing, temperature of peripheries, pulse rate, rhythm, character | ||
| Nicotine staining | Palmar erythema | ||
| Splinters | Interosseous wasting | Liver flap | |
| Capillary refill | CO 2 flap | Leuconychia | |
| Face | Conjunctival pallor or suffusion | ||
| Corneal arcus | Central cyanosis | Sclerae (jaundice) | |
| Xanthelasma | Horner’s syndrome | Aphthous ulceration | |
| Malar flush | Fetor | ||
| Neck | Jugular venous pressure | ||
| Carotid pulsation | Lymphadenopathy | ||
| Trachea | Spider naevi | ||
| Accessory muscles | |||
| Torso | Scars | ||
| Thrills and heaves | Chest expansion | Palpation | |
| Heart sounds | Percussion note | Tenderness or masses | |
| Murmur | Breath sounds ± | Organomegaly/ascites | |
| Radiation | added vocal resonance | Bowel sounds/bruits | |
| Accentuation | Gynaecomastia | ||
| Radiofemoral delay | Caput medusa | ||
| Inguinal nodes | |||
| Additional areas | Pedal oedema | ||
| Listen at lung bases | Sputum pot | PR exam | |
| Genitalia | |||
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