Clinical assessment of adults

• If emergency or person seems very unwell go straight to Early recognition of sepsis
• If clinical assessment conducted in custody — refer to your health service policy

Attention

• Culturally safe approach
• Make person feel comfortable
• Consider gender issues
• Consider need for interpreter
• Are appropriate family members present if needed
• Holistic and comprehensive
• Consider whole person — context of their lives, families and community
• Be guided by population health principles (ie accessibility, public participation, health promotion, appropriate technology and intersectoral cooperation)
• Explore the person’s illness experience, impacts, treatment goals
• Consider chronic conditions/on-going health problems/age-appropriate screening
• Be guided by context and environment
• Systematic
• History informs examination
• History, then observations or physical exam
• Share power with person
• Ensure partnership between clinician and person
• Negotiate history taking and management plan with person
• Encourage person to share in decision making and own their own health
• Build person’s self-reliance and health literacy
• Provide coordination and continuity of care
• Recognise shared care
• Succinct, pertinent, person focused documentation
• Send summaries to nominated services
• Coordinate complex care
• Collaborate with colleagues
• Utilise recall systems
• Encourage clinical reasoning
• Considers age and place, risk of person, what is most likely and what you can’t afford to miss
• Use problem solving approach to reach diagnostic hypothesis
• Promote clinical safety and quality
• Work within individual’s scope of practice
• Use endorsed best practice treatment protocols (RPHCMs), quality improvement processes and procedures 

What you need

Equipment

• Clinical record (file notes, electronic medical record)
• Clinical manuals
• Stethoscope
• Thermometer
• BP machine with range of cuff sizes
• O₂ sats monitor with range of probe sizes
• Scales and stadiometer (height measurement)
• Tape measure
• Blood glucose meter
• Blood collection equipment
• Urine pots, urine dip sticks
• Education materials about condition and/or treatment (eg displays, models, pamphlets)
• POC testing as available (eg  ECG, Hb, chronic conditions monitoring)

What you do

Before starting consult

• Check clinical record for
  
• Current and past medical and surgical history
• Current scripts and recent medications  
• Allergy status
• Last set of observations and pathology tests
• Any outstanding actions or overdue recalls
• Make sure you are in a place not to be disturbed, comfortable, well lit, private room and adequately equipped
• Consider own AND person’s safety 

Consultation procedure

• Open consult — greet person by name, introduce yourself and establish rapport — consider 4Fs – family, football, food (as in hunting) and fun
• Offer interpreter if necessary
• General impressions — consider person's appearance, demeanour, speech, hearing, gait, posture, body symmetry, any tremors, odour, dental care, skin condition and interactions with others
• Check name, next of kin and DOB
• If person different gender — check if health professional of different gender needed

Reason for presentation — Acute / Non-acute

• Story of why they presented today
• Establish concerns and expectations
• Listen, encourage, don’t interrupt and use SILENCE

History — acute presentation 

If person seems very unwell go straight to Early recognition of sepsis 

OLDCARTS

O nset — when did it start
L ocation — where does it hurt, where is problem
D uration — how long, had it before, what happened then
C haracteristics — description of pain, problem
A ggravating factors — anything that makes it worse
R elieving factors — anything that makes it better
T reatments — what have they tried, what do they think it is, how it is impacting on them and others, anything else
S igns and symptoms (other) — other problems, quick systems review, anything else you need to know to look after them

• Have they had contact with someone different, been doing anything different lately (eg travel, work, activities)
• If you can’t work it out — work backwards. What were they doing, what did they eat/drink this morning, last night, yesterday
• Explain what you are doing/thinking, why you need to ask more questions 

History — non-acute presentation

Current health review

• Immunisation status
• Appetite, nausea, change in weight
• Physical activity — when, what, how often
• Sleep patterns, energy
• Smoking/alcohol/other substance use — how much, how long, quitting experience
• Urine, bowels, periods, sexual health
• Emotional wellbeing — motivation, enjoyment, more or less happy, looking forward to anything, anxiety, self harm, domestic/family violence — 'Do you ever feel unsafe'

Medicines

• Prescribed — how long, what, when, why, any problems
• Over the counter, herbal, traditional, other people’s
• Contraception

Allergies

•  What happens when exposed

Past medical history — from patient, relatives, other clinics, hospital records

• Illnesses — as child/adult, psychological
• Accidents, injuries, family violence
• Chronic conditions
• Hospital admissions, operations
• Gynaecological/obstetric — menstrual cycle, STI’s, number of pregnancies, number of live births, child spacing, contraception

Family medical history — partner, children, parents, siblings, grandparents

Social history — home situation, education, occupation, income source, marital/de facto status, mobility, environmental issues, family violence, cultural supports and responsibilities

Clinical examination

• Use look, listen, feel, discuss
• Rapid physical assessment
• Look for signs of chronic conditions
• General appearance (alert, dehydrated, febrile, wasted) including gait and speech

• Examine nails and both hands — nicotine staining, scars, clubbing, tremor, swollen joints, cool peripheries, fungal infections
• Eyes — jaundice, anaemia, cataracts
• Mouth and tongue, hydration, dental care
• Jugular venous pressure
• Auscultate heart sounds and anterior breath sounds
• Lean person forward, observe respirations, auscultate lungs, palpate for tenderness
• Lie person flat, observe, auscultate and palpate abdomen
• Inspect/palpate both legs for swelling, perfusion, pulses and oedema

• Use history to determine any detailed examinations needed of relevant systems
  
• Skin exam
• Eye assessment
• Ear exam
• Mouth, throat, teeth and gums exam
• Lungs and respiratory system exam
• Abdominal exam
• Rectal exam
• Foot exam
• Investigations as determined from history and examination 
• Other investigations as needed — U/A, pregnancy, Hb, ECG, BMI, waist circumference
• POC testing as available and relevant
• Offer appropriate screening tests — Adult Health Check, STI check — man, woman

Examination findings

Consider

• Reason for presentation
• Other likely health issues
• Age/place/risk — persons risk given their age and the setting
• What things are often missed/can’t be missed
• What is most likely
• Seek further advice — medical consult as needed

Discuss

• Summarise and reflect on findings with person
• Explore person’s knowledge and clarify — include long and short term implications
• Use opportunities for brief intervention and health promotion as appropriate

Negotiate management plan

• Use best practice treatment protocols for management guidelines
• Discuss goals/priorities and negotiate management (including referrals) with person and significant others as appropriate — confirm management plan is acceptable to person and family
• Consider context and environment in negotiating management plan
• Plan long term management for identified risk factors, public health/preventive health issues and screening
• Ask if there are other questions, encourage and reassure
• Provide appropriate illustrated or written resources
• Agree on follow-up

Close consultation

• Cover contingencies — ensure person knows when to return, how to contact services if needed
• Check person understanding and agreement of management plan
• Provide referrals, prescriptions/medicines as needed

Documentation

• Update persons record using organisations documentation process (eg SOAP, SODAF)
• Update required recalls using organisations process
• Send letters/summaries/referral to other services identified by person

Reflect on consult

• How did it go
• What did you notice about person, about yourself or your reactions
• Identify any learning needs, remember self-care