Adapting skills for practice

Presentation in emergency

Patients presenting with collapse or multiple injury may clearly be unable to engage in the normal systematic process of history taking and examination. The approach to the acutely ill or deteriorating patient is covered in depth in Chapter 18 , but this clinical context demands a different approach:

• Triage of airway, breathing and circulation for immediate stabilisation

• Identifying the key elements of the history from a third party (witness, family) – including the patient’s normal level of functioning, the time course of the illness, major prior illnesses and any key precipitating events (e.g. medication taken, injury sustained).

• Interleaving further selected elements of examination with critical investigations (e.g. chest x-ray, ultrasound) and resuscitation treatments such as establishing intravenous access and administering fluids and/or emergency drug treatment.

Seamlessly merging these elements of assessment, triage and treatment is a skill which becomes highly developed in Emergency Department clinicians but should be practiced by all, as the sudden need to assist a collapsed or injured patient is something with which any clinician may be faced unexpectedly (see below).

Presentation with localised illness

Some patients present with a well-defined clinical problem in a specific system, for example, an infected insect bite or a localised bony injury. In this situation, the temptation may be to confine history and examination to the affected incident and area. However, despite the resulting saving of time, this may not serve the patient well. Although a comprehensive history and examination may not be appropriate or even possible in this situation, nevertheless, some broader questioning is nearly always required. For example, an infection may indirectly reveal previously undiagnosed diabetes, so a brief enquiry about recent weight loss, polyuria and polydipsia may be helpful. Similarly, the injured patient should always be asked about the context of the injury in case there are underlying episodes of syncope or seizure, or a background of alcohol excess, which also need to be addressed. Consider also the impact of the illness in the context of the patient’s life. For example, a hand injury may directly threaten the livelihood of a manual labourer, sports professional or musician, and may compromise the ability of frail or isolated patients to maintain their self-care.