Approach to aggressive patients

Dealing with angry/aggressive patients.

Is there any difference between anger and aggression?
- Anger is an emotion
- Aggression is a behaviour

What is your approach to angry patient?
- I adopt the RACGP check program approach, using the acronym LASSIE which stands for:

- L : listen
- A: Acknowledge, agree and apologise. It doesn't mean you need to agree with the other person but simply saying I am sorry that has happened to you may help to diffuse the situation
- S: separate. Bring the person to a quiet area
- S: Sit down. Aggression is more difficult in a sitting position
- I: indicate options. Provide options for patient to choose
- E: Encourage choice. Get the patient to choose what is available. Give him/her the feeling that they are in control

How would you follow up the patient?

- Patients often react very differently to GPs and receptionists but GPs can't function without the help with receptionist and other staff members. It is important that we protect them and discourage bad behaviour
- The issue needs to be brought up with the patient at the next appointment, re-stating the fact that this sort of behaviour is not acceptable and if it happens again, we may terminate the patient and doctor relationship. (From the check program, there is a behaviour contract template for GPs to use)

References:
check program

Approach to Scabies

key points:

1. Usually present with intense itching
2. Caused by Sarcoptes scabiei. The female mite burrows beneath the skin in order to lay eggs. The eggs hatch into tiny mites and spread out over the skin and live for only about 30 days
3. The mite antigen, in its excreta, causes a hypersensitivity rash.
4. Diagnosis is by microscopic examination of skin scrapings or by response to treatment
5. Usually spread through close contacts. Children need to be kept away from school until they complete the course of treatment.
6. According to therapeutic guideline, the treatment of choice is permethrin 5% leave on for at least 8 hours or benzyl benzoate for 24 hrs repeat after 1 week. Usually permethrin is better tolerated and less drying.
7. In kids less than 6 months, the current recommendation from therapeutic guideline is still permethrin 5 % but it also stated that permethrin is currently not licensed to be used for this purpose.
8. Other treatment for children under 6 months: sulphur 10%in white paraffin once daily for 2-3 days or chromatin 10% topically once daily for 2 -3 days
9. In immunocompromised patients, it can become crusted scabies, essentially means huge number of mites in the body known as norwegian scabies. Try to get expert opinion, treat with ivermectin 200 mcg/kg as a single dose plus topical treatment.

References:
John murtagh 5th edition
eTG

Treatment for head lice

Head lice is a common problem is school aged children.
GPs need to have an approach in dealing with this problem. Give clear instruction to parents of how to deal with it. Usually diagnosis is via clinical examination. Visualisation of nits and live lice in the hair is diagnostic.

Key points:

1. It is caused by the louse pediculus humanus capitis.
2. Patients can present with significant itching on the scalp and neck.
3. Wet combing: apply generous amount of hair conditioner and comb with fine toothed comb. The conditioner stunt the lice and stops them from crawling for 20 minutes. The method only has around 40 % successful rate.
4. permethrin 1% topically, leave for a minimum of 10 minutes; repeat treatment in 7 days (there are other treatment options, please see therapeutic guideline). Use the wet combing method the day after treatment to check for live lice. If live lice are found despite treatment, that means the lice are resistant to the product used.
5. In between treatments, use the wet combing method twice to remove all eggs less 1.5 cm from the scalp.
6. Wet combing should be repeated weekly for few weeks to ensure complete clearance.
7. Bed sheets and linens should be washed with hot water 60 degrees.
8. Treat all household members
9. Notify school but can still go to school after treatment
10. Treatment resistant: use a different product or ivermectin 200 mcg/kg as a single dose with fatty food, repeat in 7 days.

References:
- eTG
- John murtagh 5th edition

Approach to complaints

It is a difficult situation but almost unavoidable. We need an approach on how to deal with it at the exam and in real life.

We can essentially divide process of handling complaints into three steps:

First step: acknowledge injured feelings and investigate the complaint
Second step: explore options and consequences
Third step: resolving the issues 

First step: acknowledge injured feelings and investigate the complaint

• usually the clinic has a protocol in place to deal with complaints (e.g. third party involvement)
• It is important to take the complaint seriously and to give patient sufficient time to ventilate his/her concerns. 
• Remain calm
• Thank the patient for coming to discuss the issue, and acknowledge that the situation has caused her worry and concern. Demonstrate active listening by posture and verbal responses, and convey that you have understood by repeating, paraphrasing, clarifying and open ended inquiry.
• Make sure at the end of the consultation that the person receives a clear message that you are taking issue seriously and you will investigate. 

Second step: explore options and consequences

• Gather the facts: review notes, copies of reports etc. 
• If it is necessary, may need to contact MDO
• Arrange a meeting to explore what the patient wants
• provide the patient with the information you gather 
• Keeps patients informed about the investigation progress

Third step: resolving the issues 

• Clarify what will happen next 
• provide summary of what has happened so far
• explain if any changes or improvement will happen
• reach an agreement

References:
1. Check program: challenging consultations
2. Dealing with complaints by Avant

RACGP Exam

After studying and preparing for the exam for nearly 6 months, I have the chance to do an assessment today. It was a complete failure. I obviously neglected the OSCE component of the exam, so I didn't do well in the OSCE. My poor time management only left me around 15 minutes for around 10 questions in the KFP, so I needed to quickly rush through them and I don't I did well either.

After today's formative assessment, I identified some weaknesses in my knowledge:

1. Critical appraisal of journals
2. No structured approach to difficult patients e.g. angry patient, complaints against doctors
3. Poor time management
4. Poor understanding of endocrinology
5. Have not read the exam handbook
6. Does not know how to answer questions in KFP

Still has around 2 months to go. I will try to fill in those gaps before the AKT.

Approach to a travel consultation

Key points:
- Take a good history:
      > Information about the traveller
         - Age
         - Medical history
         - Medications
         - Allergies
         - Vaccination history
         - Previous travel
       > Information about the itinerary and activities
        - Reason for travel
        - Style of travel
        - Duration of stay
        - Exact destinations
        - Season/s
        - Accommodation
        - Exposures
        - Specific activities
        - Budget

- Potential issues for pre-travel consultation:

• Aircraft travel issues (e.g. reduce oxygen pressure, humidity)
• lack of fitness to travel 
• DVT risks
• Motion sickness
• Jetlag
• Altitiude illness
• Heat/cold/sun exposure
• Water safety/accidents/injuries
• Animals bites
• Insect bites
• Carrying medicines
• Accessing medical care
• Drugs and alcohol

Communicable risks - no vaccines

• Traveller's diarrhoea from causes other than enterotoxigenic E.Coli
• Dengue fever
• HIV infection 
• Amoebiasis
• Giardiasis 
• Helminthic infestations 
• Sexually transmitted infections 

Communicable risks - vaccine preventable 

• Traveller's diarrhoea due to enterotoxigenic E. Coli 
• Hepatitis A and B
• Typhoid 
• Yellow fever
• Cholera
• Diptheria/tetanus/pertussis
• Measles/mumps/rubells

Altitude sickness can occur at any altitude above 2100 metres and sometimes less, depending on the rate of ascent and individual susceptibility. Acetazolamide 125mg twice per day for 5 days starting just before flying would be appropriate. Acetazolamide is contraindicated in people with severe sulphur sensitivity, but can be tested in those with a vague history of possible sulphonamide allergy in childhood. Common adverse effects of acetazolamide include premolar tingling, flushing and frequent urination 

3 Rs provide a systematic approach to the consideration of the travel vaccination and help guide the priorities. 

Fitness to fly refers to whether a person is physically and mentally fit enough to undergo a trip  in a pressurised jet aircraft, and usually relates to the problem of sitting confined in a depressurised and lower oxygen environment for several hours. 

Malaria is an infection caused by the protozoa plasmodium, transmitted by the bite of female Anopheles mosquitoes. Foremost in prevention is avoiding exposure to theses mosquitoes. Strategies include:

- minimising exposing to the mosquito between dusk and dawn. Anopheles mosquito is a night feeder 

- wearing protective clothing including long sleeves and trousers, ideally pretreated with permethrin 9 ac common insecticide)

- wearing light coloured clothing - this is associated with reduced risk of mosquito bite

- use of 20% or greater concentration DEET insect repellents on exposed skin 

- sleeping in screened or air-conditioned rooms under mosquito nets

- using 'knockdown sprays' (sprays which create a specific rough surface) on the internal walls of accommodation. 

The decision on whether to prescribe chemoprohphylaxis is made after detailed discussion of the risks and benefits, and the realistic risk of developing malaria. 

Chemoprophylaxis is about 90 % protective in high risk areas if travellers are careful with compliance and bite reduction. (please refer to Most commonly used antimalarials currently available in Australia

"VFR"stands for visiting friends and relatives, it describes citizens and permanent residents who were born overseas (and their children) who live in Australia and are travelling to their country of origin for any purpose. 

Pregnancy and travelling: 

- requires planning 

- best time is second trimester 

- history of pregnancy complications such as pre-eclampsia, diabetes and miscarriage should be a contraindication to travelling. 

- need a letter from obstetrician to outline the progress of pregnancy and other requirement. 

Malaria in pregnancy tends to be more frequent and severe, and the risk of complications such maternal death, abortion and stillbirth are significant. 

Oral cholear vaccine reduces the risk of traveller's diarrhoea, as it has also some activity against the toxin which is implicated in traveller's diarrhoea but will not prevent traveller's''s diarrheoa or replace the need for self treatment. 

Malarial protection in children 

- advice the same as adults

- medications essentially the same (please click here to view the list and dose of the mediations) 

Drugs used for malaria chemoprophylaxis in children

Bacteria are condsidered the predominant cause ( 80-90% overall), with enterotoxigenic E.coli being the most common, followed by campylobacter jejune, shigella, salmonella and other strains of E.coli. Viral causes are thought to account for 5-10 % of cases, including norovirus and rotaviurs. Protozoal causes, such those of the guard genus, are slower to present, but may cause about 10 % of disease in long term travellers. 

The adage, ' cook it, peel it, or forget it' is good for travellers to remember but the evidence suggests most people will faiths within 48 hours. 

Oral cholera vaccine (Dukoral) which includes recombinant cholera B toxin subunit provides some cross protection against enterotoxigenic E. Coli. Two doses of the vaccine provide protection against enterotoxigenic E. Coli at 60-80% and the protective effect lasts for about 3 months. Overall, the risk reduction against traveller's diarrhoea is about 20%.

Traveller's medical kit for traveller's diarrhoea:

- anti nausea medication 

- loperimide (except in bloody diarrhoea) 

- azithromycin 

- oral rehydration sachet 

- Tinidazole may be useful for longer travel where giardia becomes more likely 

There are two golden rules in the management of a febrile returned traveller:

- an unwell febrile returned traveller needs hospital admission under an infectious diseases unit

- always consider malaria as a differential diagnosis in a febrile returned traveller where any possibility of malaria exists

Dengue fever aka "breakbone fever"

- biphasic (saddleback) fever pattern may or may not be found d

- rash is often, but not always present. Rash often becomes confluent, sparing normal islands of normal skin, and blanches under pressure. On resolution, the skin may desquamate. 

- There is often some elevation of liver transaminases and mild hyponatraemia in the acute phase of the illness. 

- often associated with leucopenia, thrombocytopaenia and low platelet counts. 

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