The above talk looks at a variety of relevant cases  focused on common reasons you'll be asked to review patients. All the cases are fictional, however it's a useful way of considering how the initial call, history and examination can help you formulate a list of differential diagnoses. 

Chest pain, dyspnoea and abdominal pain all have such a wide range of potential causes, and a focused history and examination are useful to narrow down the differential list. 

I've deliberately not separated this into medical or surgical patients as these complaints can occur in either subgroup and regardless of which team they are under the approach is similar.  This is again not an exhaustive list of investigations because patients are individual but it does consider some of the most common investigations to consider.

Every patient will need 

•Focused history

•Examination à ABCDE 

•Observations  & Targeted investigations 

•Immediate management 

•Ongoing management plan 

•Senior review if concerns 

Chest pain: 

• History taking is key 

  • Take the time to consider and ask about red flags - Age > 60, strong family history, Pain radiating to back, pain at rest or exertion or signs of shock. 

• ECG 

  • Review carefully and get a second opinion if you aren't sure 

  • See the common investigations section for interpreting an ECG 

• Bloods including troponin 

• VBG 

• May require imaging - CXR / CT 

  • Particulary in patients with symptoms suggestive of pulmonary emboli, pneumonia, pneumothorax 

Shortness of Breath: 

• History taking is key 

  • Take the time to consider and ask about red flags - severe hypoxia, respiratory rates > 30, new confusion, signs of shock, central cyanosis, stridor, associated chest pain or inability to complete sentences. 

• ECG 

  • useful to show any rate or rythym abnormalities 

  • Can also show signs of strain 

• Bloods including BNP 

• VBG or ABG 

  • Consider ABG if hypoxic or significant oxygen requirement 

• May require imaging - CXR / CT 

  • Particulary in patients with symptoms suggestive of pulmonary emboli, pneumonia, pneumothorax, aspiration, congestive cardiac failure and more.

Abdominal pain:

• History taking is key 

  • Take the time to consider and ask about red flags - Age > 60,  severe / sudden in onset, fevers, unexplained weight loss, jaundice, signs of shock or peritonism

• ECG 

  • Especially if upper abdominal pain as can be an MI 

  • Also useful if patient needs theatre

• Bloods 

• VBG 

  • Pay particular attention to lactate / acidosis 

  • Don't ignore an acidosis or raised lactate - escalate it early  

  • Look at the blood glucose - DKA can present with abdominal pain 

• May require imaging - CXR / CT 

• Abdominal pain has a huge range of differentials across many of the specialities 

Chest pain: 

• History taking is key 

  • Take the time to consider and ask about red flags - Age > 60, strong family history, Pain radiating to back, pain at rest or exertion or signs of shock. 

• ECG 

  • Review carefully and get a second opinion if you aren't sure 

  • See the common investigations section for interpreting an ECG 

• Bloods including troponin 

• VBG 

• May require imaging - CXR / CT 

  • Particulary in patients with symptoms suggestive of pulmonary emboli, pneumonia, pneumothorax 

Management 

• Dependent on clinical diagnosis 

• Most thinks like myocardial infarctions, pulmonary emboli will have a local policy around management and ongoing management that you can refer to.

Falls: 

• Another common call and reviews are often mandated by policy 

• Information gather as much as you can to triage the urgency of the review 

• On review 

  • Patient history - Do they remember the fall? Any head injury? Any other injuries? 

  • Patient examination - Make sure to include an examination of neurological status and look for any signs of injury 

  • Consider contributing factors - New infections? Cardiac cause - Chest pain, Postural hypotension or other? Low blood sugars? 

    • Investigate and treat accordingly 

• If evidence of head injury 

  • Do they need a head CT? 

  • Start neuro obs 

  • Hold blood thinning medications until you discuss with your senior. 

When to escalate:

• When red flags are present 

• When a patient doesn’t improve with intervention 

• When you’re worried

• You are unsure of diagnosis

• Patient looks critically unwell

• Escalation decisions needed

• You feel out of your depth

Disclaimer:

This is a not for profit education resource designed for new resident doctors. All information serves as a guide to help doctors approach day to day life as an F1. It is not intended as a guide to patient care and should never be used as such or in place of advice of treating clinicians or published clinical guidelines. All cases are fictional and any resemblance is purely coincidental. Additionally all images are AI generated unless otherwise stated.