Patient Assessment and Clinical Skills
What this domain tests
This domain tests systematic assessment: history taking, vital signs, physical examination, recognition of deterioration, pain assessment and accurate documentation. Questions reward a structured approach and interpretation of trends rather than single readings.
Core rules
- Use a primary survey first: airway, breathing, circulation, disability and exposure. Treat immediate threats before completing the history.
- Vital signs include temperature, pulse, respiratory rate, blood pressure, oxygen saturation and pain. Respiratory rate is the most often omitted and an early marker of deterioration.
- Normal adult resting values are approximately respiratory rate 12-20/min, heart rate 60-100/min, systolic blood pressure 90-140 mmHg, temperature 36.0-37.5 °C and oxygen saturation 94-98% on room air.
- Measure orthostatic blood pressure after lying for several minutes then standing; a fall in systolic pressure of at least 20 mmHg or diastolic of at least 10 mmHg suggests orthostatic hypotension.
- Examine the abdomen by inspection, auscultation, percussion and palpation, in that order, so palpation does not alter bowel sounds.
- Pulse oximetry measures oxygen saturation, not ventilation. It is unreliable in carbon monoxide poisoning, poor perfusion, motion and nail polish.
- Document objective findings, time, site and the patient's response.
Worked example
A 78-year-old presents with new confusion. Blood pressure is 102/64 mmHg, heart rate 112/min, respiratory rate 26/min, temperature 38.4 °C and oxygen saturation 91% on room air. No single value is extreme, but the combination of fever, tachycardia, tachypnoea, hypoxia and confusion meets escalation criteria and suggests sepsis. The reasoning is to aggregate abnormal observations, compare them with the patient's baseline, and act on the trend rather than waiting for a single critical value.
Traps that cost marks
- Acting on one reading without repeating or comparing it with baseline.
- Using a blood pressure cuff that is too small, which falsely raises the reading.
- Palpating the abdomen before auscultating bowel sounds.
- Accepting a normal blood pressure in a patient who is normally hypertensive.
- Recording only subjective impressions such as comfortable without observations.