CCFP priority topic 104 of 105
Violent/Aggressive Patient on the CCFP exam
4 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 4 key features for Violent/Aggressive Patient. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 4
Spot the risk
In high-risk groups, expect aggression, read its early signs, and plan before you go in.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosis, treatment
On the exam
A night in emergency: a drunk father with a feverish baby, and others waiting. Expect a short menu (pick several from a list).
Pick the signs that point to violence.
Common mistakes
Reading distress as threat: tears, looking away, rocking the baby, calling a partner. Or ranking drink or a long wait above his past threat to staff.
Approach
- Expect aggression in people who are drunk or high, acutely psychotic, confused, or known to have hurt or threatened staff.
- A past threat or assault on staff weighs more than drinking or a long wait.
- Watch for escalation: a fixed stare, a raised voice, clenched fists, pacing, squaring up, hitting objects.
- Distress is not threat. Crying, shame, looking away and soothing a child do not predict violence.
- Before you go in: tell a colleague, bring security or a second person, and know your way out.
- Sit so neither of you is blocked from the exit. Stay well out of reach.
- In hospital, if the risk is high, have a trained team and sedation ready before you start.
| Points to violence | Points to distress | |
|---|---|---|
| Eyes | A fixed, hard stare | Looking away, tears |
| Body | Clenched fists, squaring up, hitting objects | Slumped, or rocking and soothing a child |
| Voice | Loud, threats, swearing at staff | Quiet, crying, asking for help |
| History | Past threat or assault on staff | Worry about a sick child |
Key feature 2 of 4
Find the medical cause
Look now for a medical or mental illness behind aggression, even in a drunk patient.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generationSources Choosing Wisely Canada
On the exam
A man of 44 with diabetes and schizophrenia turns confused and agitated in your office. Expect a short menu (pick several from a list).
Pick the checks that find the cause now.
Common mistakes
Ordering what his booked visit was for: a 3-month sugar test (A1c), eye exam, mood score or memory test. Or blaming his schizophrenia and missing low blood sugar.
Approach
- Check the fast killers first: bedside blood sugar, oxygen level on a finger probe, temperature, and a look for head injury.
- Think of low sugar, low oxygen, infection, head injury, stroke, seizure, poisoning and withdrawal.
- Do not blame alcohol and wait. Drinking can hide a head injury, low sugar or withdrawal.
- Quiet is not the same as well. A patient settled by sedation still needs the work-up.
- A new fixed false belief, such as being poisoned, is psychosis. Ask who it targets.
- In a confused inpatient, get a head scan (CT) only with a fall or head injury, new weakness or other new nerve signs, or unexplained drowsiness.
- In a child who needs psychiatric admission, order screening blood tests only when the history or exam calls for them.
| Cause | Clue | Quick check |
|---|---|---|
| Low blood sugar | Insulin or gliclazide, sweating, confusion | Bedside glucose |
| Low oxygen | Fast breathing, blue lips | Finger probe |
| Head injury | A fall, bruising, drinking | Exam; CT if signs |
| Withdrawal | Alcohol or sedatives stopped, tremor | History and vital signs |
| Psychosis | Fixed false beliefs, voices | Mental status exam |
Key feature 3 of 4
Safety before assessment
Keep everyone safe first, with restraint if it is needed, and only then examine.
CFPC skill Clinical reasoning, professionalismPhase TreatmentSources Choosing Wisely Canada
On the exam
A patient with psychosis walks toward the receptionist he believes is poisoning him. Expect one best answer.
Pick the first action.
Common mistakes
Stepping into his path alone to talk him down, phoning his psychiatrist, or giving his long-acting injection, which takes days to work. Untrained staff holding him down is wrong too.
Approach
- Move staff and other patients out of the patient's path. Leave the room if you must.
- Call 911 in an office, or security in hospital, as soon as violence looks likely.
- Talk only when it is safe: one calm speaker, short sentences, real choices, out of reach.
- Restraint needs a trained team. Untrained office staff should not hold a patient down.
- In a drunk patient, a benzodiazepine adds to alcohol and can slow breathing. Watch the airway after any sedation.
- Older adults with delirium or dementia: avoid physical restraint. Use family or a sitter, and the least restrictive step.
- Older adults: no benzodiazepine as first choice for agitation. In dementia, an antipsychotic only after non-drug steps fail and the threat is imminent.
| Office | Hospital or emergency | |
|---|---|---|
| Help | Call 911 | Call security |
| Restraint | Not by untrained staff | Trained team, least restrictive, per policy |
| Then | Assess once police have made it safe | Assess, and keep looking for the cause |
Key feature 4 of 4
An office plan
Write a clinic plan for aggression, and make sure every staff member can use it.
CFPC skill ProfessionalismPhase Treatment
On the exam
After a patient threatened her, your receptionist froze. Expect a short menu (pick several from a list) of changes for the office.
Pick the changes that protect the whole team.
Common mistakes
Fixes aimed at one part: discharging the patient, training only her, or a panic alarm with no agreed response. None gives the team shared roles.
Approach
- Write the plan with the whole team: who calls for help, who moves patients away, who speaks.
- Agree on one alarm or code word, and what each person does when it sounds.
- Plan the exits and a safe room. Never leave one staff member alone in the clinic.
- Train every new staff member, and practise the plan together.
- Flag a past threat or assault in the chart, so staff know before the visit.
- After any incident: write it down, report it, care for anyone hurt, and review whether the plan worked.
- Do not end care because acute illness drove the aggression. Treat the cause and set clear limits.
Flashcards
Answer it first, then check.
KF 1A drunk father once threatened staff here. Which risk factor matters most?
His past threat to staff. It predicts violence more than drinking or a long wait.
KF 1Name three signs that a patient may be about to strike.
Any three: a fixed stare, clenched fists, a raised voice, pacing, squaring up, hitting objects.
KF 2An agitated man on gliclazide is sweating and confused. What do you check first?
His blood sugar at the bedside. Gliclazide can cause low sugar that looks like a behaviour problem.
KF 2Sedation has settled an agitated patient. Is the work-up done?
No. Quiet is not better. Keep looking for the cause, such as low oxygen or head injury.
KF 2A confused inpatient has no fall and no new nerve signs. Head CT?
Not routinely. Keep the scan for a head injury, new nerve signs or unexplained drowsiness. Source: Choosing Wisely Canada
KF 3An older adult with delirium is agitated on the ward. What do you try first?
Non-drug steps: family or a sitter, and a calm room. Avoid restraint and a benzodiazepine first. Source: Choosing Wisely Canada
KF 3An agitated patient walks toward a staff member in your office. First move?
Get people out of the way and call 911. Do not step in alone or restrain without a team.
KF 4What makes a panic alarm useful?
A response everyone has agreed and practised: who calls, who clears the room, who speaks.
FAQ
Which Canadian guideline covers violent patients?
No national clinical guideline covers it. Provinces set workplace safety rules, and your college sets the rules for ending care. The exam tests safe, sound judgement, not a document.
Does the exam want me to talk the patient down first?
Only when it is safe. Talk first if the patient is agitated but not yet violent and help is close. Once violence starts, getting people safe and calling help come first.
Can I end care with a patient who threatened staff?
Not because of an illness you can treat, such as acute psychosis. For repeated threats, follow your provincial college's policy. Make sure the patient can still get urgent care elsewhere.
Are older adults handled differently?
Yes. Agitation in an older adult is often delirium or dementia. Look for the cause and use non-drug steps first. Avoid restraint, and do not pick a benzodiazepine first.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Choosing Wisely recommendationsChoosing Wisely Canada