TELEPHONE CONSULTATION HELPER

Orchard Croft Fax 01924 279459

 Netherton Fax 01924 278404

 Urgent Ambulance 01924 834502

Bed Bureau 0845 3044567

 PGH/DDH/PGI 0844 8118110

SPOC 01924 327591

SOCIAL CARE DIRECT 0345 8503503

HOSPICE 213900

ROS 07824801665

WATERTON HUB 01924 302845



Box 9.15 Guidance on the telephone management of anxiety and depression

Information needed

Is this an acute or longstanding problem?

  • past psychiatric history pre-morbid personality/collateral history
  • drug and alcohol history/prescribed medication.
  • Is the patient's mental state reasonable under the circumstances?
  • bereavement relationship or financial problem/stress at work.
  • Is the patient intoxicated?
  • slurred speech disinhibition.
  • Is the patient at risk of harming themselves or others?
  • suicidal ideation or intent/threats to others.
  • What sources of support are already available?
  • friends/relatives/key worker.

Telephone management appropriate if

  • mental-state examination can be carried out (apart from appearance)
  • there is no risk of suicide or self harm
  • the patient has insight into the problem.

Telephone advice

  • Listening.
  • Brief psychological intervention
  • reframing homework leaflets.
  • Adjust medication temporarily.
  • Worsening symptoms requiring further contact:
  • increasing anxiety
  • deepening depression
  • thoughts of self-harm or suicide develop.

Face-to-face consultation appropriate if

  • there is a risk of self-harm or suicide
  • the patient is intoxicated (delay appointment until sober)
  • new medication is indicated
  • referral or admission to hospital is likely to be required.

Panel 166 anxiety

Box 9.2 Guidance on the telephone management of cough z breathlessness

Information needed

  • Is this a new or recurring problem?
  • preceding URTI
  • pre-existing chronic lung disease.
  • Is the cough dry or productive?
  • purulent/blood-stained/frothy.
  • How is the patient's breathing affected?
  • respiratory rate
  • wheeze
  • recession.
  • Is there any chest pain?
  • constant
  • on inspiration (pleuritic)
  • on coughing.
  • How ill is the patient?
  • sepsis/hypoxia/dehydration/hypotension.
  • What are the caller's concerns?
  • bronchitis/pneumonia.

Telephone management appropriate if

  • acute self-limiting viral URTI or LRTI
  • no significant constitutional symptoms
  • wheezy breathlessness in a known asthma or COPD patient with a scl management plan.

Telephone advice

  • Rest.
  • Increase fluid intake.
  • Steam inhalation.
  • Antipyretic medication, if applicable.
  • Worsening symptoms requiring further contact:
  • constitutional symptoms develop
  • respiratory distress/increasing respiratory rate.

Face-to-face consultation appropriate if

  • breathlessness without wheeze in an asthma or COPD patient
  • risk factors for asthma mortality
  • breathlessness is a new symptom
  • stridor in croup or laryngitis
  • significant constitutional symptoms.


Box 9.11 Guidance on the telephone management of cystitis in women

Information needed

  • Is the patient pregnant or could she he?
  • increased likelihood of ascending infection
  • limits choice of antibiotic.
  • Do t lie symptoms refer to acute inflammation of the bladder?
  • vaginal discharge vulval inflammation.
  • Are there any associated symptoms?
  • fever vomiting/loin pain/blood in the urine,
  • What treatment lias the patient tried so far?
  • analgesia/additional fluids/alkaline salts.

Telephone management appropriate if

  • cystitis is uncomplicated.

Telephone advice

  • Alkaline salts (potassium citrate) made up into drinks.
  • For first episode mid-stream urine specimen for laboratory microscopy and cul­ture.
  • Antibiotic treatment:
  • trimethoprim nitrofurantoin cefalcxin amoxicillin.
  • Advice on prevention, e.g. pass urine after intercourse.
  • Worsening symptoms requiring further contact:
  • no response to antibiotic
  • development of fever and/or loin pain.



Face-to-face consultation appropriate if

  • UTI precipitates premature labour
  • pyelonephritis is likely.


Box 9.9 Guidance on the telephone management of dental problems

Information needed

  • Is the patient registered witli a dentist or had dental treatment recently?
  • assess access to emergency dental services
  • complications of dental treatment:
  • bleeding/malaise.
  • How does the pain respond to simple analgesics?
  • if little response or none consider:
  • infection/exposed nerve.
  • Art- there any worrying features?
  • fevcr/trismus/ dysphagia airway obstruction.

Telephone management appropriate if

  • no worrying features
  • care can be taken over or continued by dentist.

Telephone advice

  • Analgesia:
  • NSAIDs/paracetamol and codeine.
  • Antibiotic:
  • amoxicillin/metronidazole.
  • Advise patient to contact dentist at first available opportunity, OR
  • provide patient with information about emergency and routine access to dental care.
  • Worsening symptoms requiring further contact:
  • symptoms deteriorate despite treatment
  • worrying fwiturcs develop
  • patient unable to register with a dentist.


Face-to-face consultation appropriate if

  • bleeding or history of trauma
  • one or more worrying features present . referral to hospital oral surgeon likely.


Box 9.10 Guidance on the telephone management of diarrhoea Information needed

  • Is this a rapid-onset gastrointestinal disturbance with a likely environmental cause?
  • exposure to another person with diarrhoea
  • contaminated food source.
  • What is the patient's state of hydration?
  • urine output/postural dizziness
  • skin turgor/anterior fontanelle.
  • How vulnerable is this patient to the effects of dehydration?
  • extremes of age
  • comorbidity
  • medication, e.g. corticosteroids.
  • Is there any associated abdominal pain?
  • constant/colicky
  • mild/moderate/severe.

Telephone management appropriate if

  • patient is usually fit and well
  • able to tolerate oral fluid
  • any abdominal pain is mild or moderate and colicky.

Telephone advice

  • Rehydration with glucose and electrolyte solutions.
  • Avoid infecting others.
  • Antidiarrhoeal drugs:
  • loperamide 4 mg stat then 2 mg after each loose stool,
  • Stool specimen for culture for:
  • prolonged symptoms
  • food workers
  • returning travellers.
  • Antibiotics:
  • metronidazole in returning travellers 400 mg tds tor five days.
  • Worsening symptoms requiring further contact:
  • dehydration
  • colicky pain intensifies or becomes constant.


Face-to-face consultation appropriate if

  • patient is likely to be, or at risk of becoming, dehydrated
  • referral for assessment ol the acute abdomen is likely.


Box 9.3 Guidance on the telephone management of earache

Information needed

  • Is the earache arising in the context of URTI?
  • If not, are there any associated ear symptoms?
  • discharge/itch
  • hearing loss/vertigo.
  • Has the patient had any previous ear surgery?
  • tympanostomy tubes
  • eardrum repair.
  • Arc there problems with any other head and neck structures -
  • cervical spine (C2)
  • wisdom teeth/sinuses (V)

pharynx/larynx (IX, X).

Telephone management appropriate if

  • earache arises in context of URTI
  • antibiotics arc not indicated and caller happy with this, OR
  • 'wait and see' approach to antibiotics is acceptable to caller.

Telephone advice

  • Analgesia (paracetamol, ibuprofen, codeine)
  • Keep ear dry for patients with otitis externa.
  • Worsening symptoms requiring further contact:
  • pain persists or intensifies despite analgesia
  • worrying features develop.


Face-to-face consultation appropriate if

  • ear is discharging
  • ear is vulnerable (only hearing ear, previous surgery)
  • worrying features (vertigo, hoarseness, dysphagia, facial weakness)
  • antibiotics or hospital referral are indicated.


Box 9.4 Guidance on the telephone management of sore and or discharging eyes

Information needed

  • Is there an associated viral URTI?
  • Has the eye been subjected to trauma?
  • Is there a possibility of a foreign body in the eye?
  • corneal abrasion is associated with a foreign-body sensation.
  • Has there been any deterioration in visual acuity?
  • Has there been any recent eye surgery?
  • Does the patient wear contact lenses?
  • Is this a recurring problem, e.g. seasonal?

Telephone management appropriate if

  • history is consistent with acute conjunctivitis:
  • infective/allergic
  • the visual acuity has not changed.

Telephone advice

  • Bathing an infant's sticky eyes.
  • OTC medicines:
  • antiseptic ointment
  • chloramphenicol ointment
  • sodium cromoglycate
  • artificial tears.
  • Prescribed medicines:
  • other antibiotic ointment or drops.
  • Worsening symptoms requiring further contact:
  • if unilateral, the other eye becomes involved
  • visual acuity deteriorates.


Face-to-face consultation appropriate if

  • the diagnosis is uncertain
  • trauma was involved or a foreign body may be present
  • there is a reduction in visual acuity
  • referral to an ophthalmologist is likely.


Box 9.1 Guidance on the telephone management of acute febrile illness in children

Information needed

• What is the temperature?

  • Method of measurement
  • Reliability of method
  • Duration of temperature
  • changes over time.

What are the associated symptoms?

  • none
  • respiratory gastrointestinal, urinary  OR  rash.


  • What is the general condition of the child?
  • colour/activity/warm or cold extremities
  • feeding and drinking/urine output
  • changes over time.
  • What arc the parent's/carer's ideas and concerns?
  • fear of grave diagnosis
  • unanswered questions.

Telephone management appropriate if

  • diagnosis fairly clear
  • infection is self-limiting
  • child in reasonable condition
  • no rash apart from viral exanthema
  • caller willing to accept reassurance and advice.

Telephone advice

  • Increase fluid intake.
  • Antipyretic medication.
  • Physical cooling measures.
  • Worsening symptoms requiring further contact:
  • child develops signs of dehydration
  • child develops a rash (if no viral exanthema at initial contact)
  • temperature increases further.



Face-to-face consultation appropriate if

  • diagnosis uncertain
  • infection likely to require intervention
  • child in poor condition
  • non-specific or unrecognisable rash
  • caller unwilling to accept reassurance and advice.

Box 9.8 Guidance on the telephone management of headache and head injury

Information needed

  • What are the characteristics of the headache?
  • unilateral/band-like/occipital bitemporal
  • throbbing/constant/worse in mornings.
  • Is this a new or recurring problem?
  • analgesic use/history of migraine.
  • For spontaneous headache, what are the associated symptoms?
  • nausea/vomiting
  • neck stiffness/photophobia.
  • For head injuries, what are the associated symptoms?
  • amnesia/vomiting/drowsiness.
  • What concerns does the patient have?
  • intracranial haemorrhage/brain1 fumoW/hyptrtension.

Telephone management appropriate if

  • the history suggests:
  • tension headache
  • Migraine
  • minor head injury.



Telephone advice

  • Rest.
  • Relaxation.
  • Analgesia (unless patient is overusing).
  • Worsening symptoms requiring further contact:
  • drowsiness
  • vomiting
  • confusion
  • Meningism.


Face-to-face consultation appropriate if

  • the history suggests:
  • impaired conscious level
  • meningism
  • prolonged migraine attack
  • raised intracranial pressure.


Box 9.7 Guidance on the telephone management of other musculoskeletal pain and injuries

Information needed

  • Was the onset of tlie pain or impairment spontaneous?
  • arthritis prosthetic joint
  • risk factors for DVT.
  • Was the onset of the pain or impairment the result of an injury?
  • mechanism of injury.
  • Does the patient need the services of an A&E department?
  • fracture/dislocation
  • neurovascular trauma/risk of permanent impairment.
  • Has the patient been deliberately injured and are they safe?
  • abuse/assault ongoing risk.
  • Is the patient able to look after himself or herself and is there a suitable carer?
  • social history and functional assessment.

Telephone management appropriate if

  • mechanism of injury unlikely to cause fracture, dislocation permanent impairment.

Telephone advice

  • Rest initially, then mobilise.
  • Apply ice pack.
  • Elevate if swollen.
  • Analgesia.
  • Worsening symptoms requiring further contact.
  • increasing pain/swelling
  • further loss of movement function
  • signs of infection
  • signs of impaired circulation.


CONSIDER PHYSIO FIRST APPT


Face-to-face consultation appropriate if

  • treatment is provided in primary care for minor injuries
  • hospital assessment or admission is likely.


Box 9.5 Guidance on the telephone management of rashes and other skin problems

Information needed

  • What does the lesion or rash look like?
  • vesicular/pustular/macular/urticarial/pigmented.
  • Is the lesion single or are there multiple lesions?
  • dermatome/trunk/limbs/flexures.
  • What arc the associated symptoms, if any?
  • itchy/painful/weeping/crusted/constitutional symptoms.
  • To what has the patient been exposed?
  • drugs/chemicals/foods/viruses/plants/insects/animals.
  • If the lesion is a boil at what stage is it?
  • pointing discharging.


Telephone management appropriate if

  • sepsis can he reasonably excluded in the history
  • a reversible environmental cause can be identified
  • OTC treatments or home remedies are acceptable
  • the condition is expected to resolve spontaneously.



Telephone advice

  • OTC medicines:
  • antihistamine for allergic reactions
  • 10 per cent crotamiton or 1 per cent hydrocortisone cream tor itchy lesions
  • dressings.
  • Exposure avoidance.
  • Worsening symptoms requiring further contact.
  • lesion or rash spreads
  • lesion or rash becomes infected
  • patient becomes unwell.


Face-to-face consultation appropriate if

  • diagnosis not clear from caller's description
  • the patient is unwell
  • surgical intervention may be required, e.g. incision of an abscess
  • prescribed drugs may be required, e.g. antivirals, potent topical steroids.


Box 9.6 Guidance on the telephone management of spinal pain and injuries

Information needed

  • How mobile is the patient?
  • walking
  • limping/not weight-bearing
  • bed bound.
  • Are there any red flags?
  • age > 55/age < 20
  • limb weakness/sphincter disturbance
  • night pain/weight loss.
  • Is the patient capable of work?
  • self-certificate/medical certificate/self-employed.
  • What analgesia has the patient tried so far and what is available in the house?
  • non-steroidal anti-inflammatory drugs
  • paracetamol and codeine.

Telephone management appropriate if

  • the history is short (< 1 week)
  • no red flags
  • analgesia is accessible and adequate.

Telephone advice

  • Mobilise the spine.
  • Change position frequently.
  • Apply heat or icepacks.
  • Regular analgesia.
  • Worsening symptoms requiring further contact:
  • pain more severe or unresponsive to drugs
  • limb weakness or numbness
  • urinary retention or incontinence.

Face-to-face consultation appropriate if

  • the history is long (> 1 week)
  • one or more red-flag features are present
  • home remedies or OTC analgesics are insufficient
  • referral to a physiotherapist or consultant may be required.


Box 9.13 Guidance on the telephone management of emergency contraception

Information needed

  • Is the patient pregnant or could she be?
  • last menstrual period.
  • Have there been any other episodes of unprotected sex in the current cycle?
  • more than 72 hours ago
  • more than five days ago.
  • How long ago was the most recent episode?
  • What are the woman's usual contraceptive arrangements and are they satisfactory to her?


Telephone management appropriate if

  • patient eligible for oral treatment.


Telephone advice

  • Levonorgestrel 0.75 mg tablets:
  • one tablet stat followed by one 12 hours later, OR
  • two tablets in a single stat dose.
  • Spotting may occur after two or three days.
  • Next period may be a few days early or late.
  • Worsening symptoms requiring further contact:
  • report if next period one week overdue.



Face-to-face consultation appropriate if

  • risk of ST1
  • unprotected intercourse more than 72 hours ago.


Box 9.14 Guidance on the telephone management of vaginal bleeding in early pregnancy

Information needed

  • When was the patient's last menstrual period and has a pregnancy test been positi
  • How heavy is the bleeding?
  • spotting/like a period/heavier than a period.
  • What is the nature of any associated pain?
  • mild/moderate/severe
  • colicky/constant
  • midline/unilateral.
  • Have products of conception been passed?
  • sac/fetus/placental fragments.
  • How is the woman feeling emotionally?
  • available support.

Telephone management appropriate if

  • patient is otherwise well
  • bleeding no heavier than a period
  • pain is absent or midline, mild and cramping.

Telephone advice

  • Rest.
  • Fetal viability ultrasound scan to be arranged.
  • Worsening symptoms requiring further contact:
  • pain more severe
  • bleeding heavier
  • pain to one side.


Face-to-face consultation appropriate if

  • patient is unwell
  • bleeding is heavier than a period
  • pain is moderate or severe and cramping
  • any lateralised pain.


Box 9.12 Guidance on the telephone management of vulval and vaginal thrush

Information needed

  • Is the patient pregnant or could she be?
  • Arc the symptoms predominantly vulval?
  • soreness/itch/superficial dyspareunia.
  • Vaginal?
  • pain thick white or cream-coloured discharge deep dyspareunia.
  • Or both?
  • Are there any constitutional symptoms?
  • malaise/thirst weight loss.
  • Has the symptom arisen from intercourse with a new partner?
  • What has the patient tried so far?
  • topical antifungal natural yoghurt.

Telephone management appropriate if

  • diagnosis is clear from history
  • concurrent ST1 unlikely
  • no constitutional symptoms.

Telephone advice

  • Topical antifungal:
  • vaginal - clotrimazole pessaries 500 mg once or 200 mg daily for days
  • vulval - clotrimazole cream 1 per cent apply bd or tds tor 3 to 5 days
  • OR, oral antifungal:
  • fluconazole 150 mg stat.
  • Advise patient to inform sexual partner, who may also require treatment.
  • Worsening symptoms requiring further contact:
  • no response to treatment
  • constitutional symptoms develop.

Face-to-face consultation appropriate if

  • vaginal swabs are indicated
  • recurrent episodes
  • risk of concurrent STI
  • adequate treatment has failed
  • constitutional symptoms are present.