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Assessment - Coggle Diagram
Assessment
Review of systems
GI- jaundice, weight loss, loss of appetite, dysphagia, nausea/vomitting, indigestion/heartburn, abdominal pain, distension, diarrhoea, constipation- blood/mucus in stools. flatulence
Skin - bruising, rash, cyanosis- lips, fingers, jaundice
Resp- breathing, wheeze, cough, SOB, pain, sputum, haemoptysis, orthopnoea
MSK- pain, stiffness, swelling, inflammation, movement restriction, loss of function, locking, giving way, weakness, numbness, paresthesia. Colour, Sensation, Movement
GU - frequency, volume, urgency, nocturia, dysuria, haematuria, hesistancy, poor flow, feeling of incomplete emptying
CVS- chest pain, palpitations, oedema (ankles/legs), SOB, cough, wheeze, sputum
General- fever, rigors, nightsweats, weight loss, fatigue, skin rashes, bruising
Neurological- fits/falls, LOC, headache, dizziness, vision/hearing, memory loss, acute onset confusion, neck stiffness, photophobia Motor: weakness/wasting, new onset incontinence Sensory: pain, numbness, tingling
ENT: hearing loss, tinnitus, otalgia (earache), Nose: rhinorrhoea (runny nose), epistaxis, Throat: sore throat, odynophagia(painful swallowing)
Obs- PV bleeding/discharge, pain, weight loss
Eyes: vision affected, pupil reacting, blood shot
Mental Health - new onset confusion, delirium
Past Medical Hx
Jaundice or liver disease
Asthma/COPD
MI/Angina
Hypertension
Thyroid problems, TB
Renal Disease- CKD, Rheumatics
Epilepsy
Anaemia
Diabetes/Dementia
Stroke/Surgical Hx
Past blood hx- egfr, na,lfts
Drug Hx
Diuretics
Metformin
ACE inhibitors - ending in pril
NSAIDS
ARBs - ending in sartan
Allergies
OTC, herbal medication, illegal drugs
Anticoagulants
Chief complaint
PMHx see below
SOCRATES- symptom assess- Site, onset, character, radiate, associate, timing, exacerbated, score
Impact on life
Chief complaint
DHx see below
Shx see below
FHx see below
Review of systems
Social Hx
Lives with
Level of support required
Smoker/alcohol
Travel Hx
Visitors
ACP/EOL, Hospital admission
Red Flags
Haemoptysis, haemetemsis, maleana
unexplained weight loss
sudden onset pain
loss of consciousness, next onset confusion
non resolving chest pain
Initial consultation
Airway Breathing Color/circulation, Disability, Exposure assessment
GCS
Ideas,Concerns, Expectations- AVPU
NEWS score
Safety netting
worsening of symptoms
new onset of symptoms
failure of treatment
Side effects of treatment
DDx
Treatment Plan & Further Ix