Clinical Assessment for AHW and ANM: History, Examination and Warning Signs

Introduce yourself, confirm the person’s identity, explain what you need to do and obtain consent. Use a private, accessible setting and an interpreter when needed. For intimate examinations, follow current chaperone, safeguarding and facility rules.

Before a long history, look for immediate threats: severe breathing difficulty, shock, uncontrolled bleeding, altered consciousness, convulsions or another time-critical condition. Begin emergency action and referral within your role when delay would be unsafe.

Record the chief concern in the patient’s own words and clarify onset, course, severity, associated symptoms and factors that worsen or relieve it. OPQRST or SOCRATES can organize pain assessment without replacing open listening.

Relevant history may include previous illness and operations, medicines and allergies, family history, occupation, exposures, travel, nutrition, tobacco or alcohol, immunization and social circumstances. Ask only what is relevant, explain sensitive questions and protect confidentiality.

Pregnancy-related assessment may require menstrual, pregnancy, birth and postpartum history, current symptoms and danger signs. Use respectful language and never assume pregnancy status, sexual activity or family structure.

For children, obtain information from the caregiver while observing and engaging the child appropriately. Check feeding, immunization, growth, activity and recognized danger signs using the current national child-health approach.

Use inspection, palpation, percussion and auscultation as appropriate to the complaint, setting and your competence. Explain each step, expose only the area necessary, use infection-prevention measures and stop if consent is withdrawn.

Record temperature, pulse, respiratory rate, blood pressure and oxygen saturation when indicated and available. Normal ranges vary with age, pregnancy, activity, altitude, medicine and illness; one textbook number should not replace clinical context or current protocols.

Murphy sign may support suspicion of acute cholecystitis; right-lower-quadrant tenderness may occur in appendicitis; neck stiffness may occur in meningitis; chest indrawing can indicate serious respiratory illness in a child; and bruising patterns after trauma can raise concern for significant injury.

No single sign reliably confirms these conditions. Cullen or Grey Turner bruising can occur with internal bleeding but is uncommon and late. Homan sign should not be used to diagnose or exclude deep-vein thrombosis because it is unreliable and forceful testing may be harmful. Use validated assessment and urgent referral when serious disease is possible.

A referral note should state the concern, relevant history, findings and vital signs, treatment already given, allergies, reason and urgency. Stabilize within scope, communicate with the receiving service when possible and arrange safe transport.

Urgent warning signs include severe respiratory distress, low oxygen saturation, shock, major bleeding, new focal weakness, reduced consciousness, repeated convulsions, stiff neck with severe illness, severe dehydration, acute abdomen, significant trauma and pregnancy bleeding, severe headache or visual disturbance.