Physical illness in psych pt Flashcards

1
Q

Approach to a physically ill patient (steps)

A
History
Physical Exam
Differential Diagnosis
Special Investigations
Collateral
Immediate, Medium, Long term management
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2
Q

Name the risks of overlooking a physical illness

A

Emergency room setting

Serious and reversible causes may be missed e.g. meningitis
Transference and CT issues
High morbidity and mortality
Vulnerable patients
Litigation
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2
Q

Name the risks of overlooking a physical illness

A

Emergency room setting

Serious and reversible causes may be missed e.g. meningitis
Transference and CT issues
High morbidity and mortality
Vulnerable patients
Litigation
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3
Q

Who should we worry about wrt physical illness in psych pts

A
  • Late onset or sudden onset
  • Known underlying medical condition
  • Abnormal vitals
  • Fluctuation of symptoms
  • Atypical presentation e.g. VH; OH; TH
  • Absence of personal/family hx
  • Illicit substance use
  • Medication use
  • Treatment resistance/ adverse reactions
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4
Q

Which condition is the most dangerous?

A

Delirium/acute confusional state

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5
Q

Which condition is the most dangerous?

A

Delirium/acute confusional state

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6
Q

Delirium DSM criteria

A

A disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment).
The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception).
The disturbances are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple aetiologies

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7
Q

Delirium DSM criteria

A

A disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment).
The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception).
The disturbances are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple aetiologies

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8
Q

Specifiers for delirium according to DSM 5

A

Hyperactive delirium: level of psychomotor activity increased, may be accompanied by mood lability, aggitation , and/or refusal to co-operate with medical care
Hypoactive delirium: decresed level of psychomotor activity that may be accompanied by sluggishness, lethargy, may approach stupor
Mixed level of activity: normal psychomotor activity even though attention and awareness are disturbed. Activity level may fluctuate

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9
Q

Management of delirium

A

Treat the underlying cause!

Supportive management: ABCs; hydration; nutrition; restore electrolytes
Continuous orientation, limit stimulation (quiet)
Severe agitation: short-acting benzodiazepines
Behavioural disturbance: LOW dose antipsychotics (haloperidol; risperidone)
Often multiple causes

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10
Q

Management of delirium

A

Treat the underlying cause!

Supportive management: ABCs; hydration; nutrition; restore electrolytes
Continuous orientation, limit stimulation (quiet)
Severe agitation: short-acting benzodiazepines
Behavioural disturbance: LOW dose antipsychotics (haloperidol; risperidone)
Often multiple causes

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11
Q

What is important when taking the history of the patient

A

Onset
Symptom cluster
Co-morbid medical conditions
Past medical; surgical and psychiatric hx
Substances
Systemic enquiry
Baseline level of function ? Functional decline

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12
Q

What is important during the physical exam?

A
Abnormal vital signs: Temp; BP; HR and RR
Level of consciousness ? fluctuates
Evidence of systemic illness: 
CNS
HIV
Organ systems
Substance abuse
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13
Q

Which investigations could you do?

A

Guided by clinical picture
Cost considerations
Basic screen: WCC; Na; K; Cr; RPR
Consider toxicology screen
NB: Geriatric patients: Urine dipstix, CMP, TSH, B12
Specific conditions: e.g. HIV – consider LP and imaging
3D-CAM Scale: 3 minute Confusion assessment method: 1. acute of fluctuating course and 2. Inattention and either 3. Disorganised thinking or 4. Altered level of consciousness Marcantanio E et al Ann int Med 2014;161(8) : in press

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14
Q

What are the treatment considerations?

A

✔ No medical illness: proceed with MHCA and psychiatric Mx
Medical illness underlying symptoms:
Medication sensitivities e.g. EPSE’S
Drug-drug interactions
Pharmacodynamics and pharmacokinetics
Short-acting benzodiazepine e.g. lorazepam
Both: Collaborative approach (C/L team)

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15
Q

Why does a chronic psychiatric illness shorten lifespan? (Death 25yrs earlier)

A
Multiple contributing factors:
Lifestyle/nutrition
“downward drift”
Access to health
Smoking/alcohol/substances
Medication side effects
Stigma