Patient assessment: a reflective case study

Abstract

The three ‘C's of physical assessment—capacity, consent and communication—could be compared to the ‘ABCs' of resuscitation; without all three you will make very little, if any, progress. But do we give these aspects the attention they deserve, especially in time critical situations? This case study is based on a 76-year-old female who presented at Accident and Emergency (A&E) with central chest pain, diarrhoea and vomiting, productive cough and pyrexia. The aims of this case study are to discuss the impact of 21st century legislation on patient assessment, demonstrate the importance of objective, structured history taken and investigate the subjective nature of physical examination. In a world of waiting lists and litigation some argue that we should let technology do the leg work—ultrasound, chest x-rays, magnetic resonance imaging (MRI) and computed tomography (CT)—why use a stethoscope?