EM Psych 2:Psychiatric Evaluation Flashcards
number one cause of disability worldwide
depression
remarks on medical clearance
evaluative process for identifying primary or comorbid medical conditions
Patients with no known psychiatric history who present with altered mental status or new-onset psychosis are presumed to have an underlying medical disorder or an “organic” cause until proven otherwise
Assuming a psychiatric condition for first-time episodes is ill advised because a psychiatric condition is a diagnosis of exclusion
High-risk psychiatric situations
suicidal or homicidal ideation,
psychotic or violent behaviors
risk for elopement
cornerstone of the medical stability assessment
physical examination
Where the history and review of systems may prove troubling to decipher, the physical exam is more objective and can lead to an underlying medical disorder as the root or exacerbating cause of symptoms
Historical features suggestive of medical causes for the psychiatric presentation
no previous psychiatric history
recently hospitalized or with symptoms suggestive of possible infections
recent medication changes
sudden changes in behavior
visual hallucinations
extremes of life; age >40y or <12y
new-onset seizure
recent memory loss
history of substance abuse
physical examination features suggesttive of organic causes of psyciatric complaints
abnormal vital signs
fluctuating level of consciousness/alertness (e.g., clouded sensorium)
significantly decreased LOC (GCS <8)
Focal neurologic findings (e.g., new-onset seizure, inability to walk unassisted)
Ophthalmologic abnormalities (e.g., rotary nystagmus)
Evidence of trauma
Abnormal dermatologic manifestations (e.g., rashes, purpura, jaundice, uremic frost, cool, mottled extremities)
Abnormal mental examination or Quick Confusion Scale
Visual hallucinations
remarks on application of violent restraints
Application of violent restraints is usually accomplished by a team of 5 members with 1 team leader and 1 person for each limb
Remarks on establishing cooperation and rapport in the psychiatric patient
Always introduce yourself clearly
Establish eye contact
Reuse terms the patient uses to describe their condition before asking for clarification; this makes the patient feel heard
Start with open-ended questions because they are best to establish therapeutic rapport
Transition to close-ended questions if open-ended questions are not productive
Last resort: Yes or no and multiple-choice questions
Sedation assessment tool
0 awake and calm, cooperative with normal speech
1+ anxious and restless with normal to talkative speech
2+ very anxious and agitated with loud outbursts
3+ combative, violent, out of control with continual loud outbursts
How to treat SAT 3+ patients?
Physical restraint
Lorazepam 1-2 mg IM
AND
Haloperidol 5-10 mg IM
OR
Olanzapine 5-10 mg im
OR
Droperidol 2 mg IM
A crucial element that’s often missed in involuntary admission of psychiatric patients
There must be a prospect of recovery if the patient is treated involuntarily.
Thus, patients with intellectual disabilities, autism spectrum disorders, or substance use disorders may not qualify for involuntary admission no matter how dramatic their presentation.
the core criteria that dicdtate involuntary transport to the ED are typically divided into 3 categories:
1) harm to self
2) harm to others
3) continuing deterioration without treatment, to the extent where self-care and self-preservation are doubtful
may manifest with
- catatonia
- self-starvation
- eating disorders
- severe psychosis with distortion of reality
Describe “Capacity”
- ability to make a decision about a specific health matter at a discrete point in time
- includes ability to understand risks and benefits of the suggested intervention; repercussion of declining it; and alternative choices
Describe “Compentency”
legal term decided by court and extends to financial, health, and personal matters
not a dynamic concept like a capacity
Absence of compentence usually implies the presence of a legal guardian, either an individual or a court-appointed entity.
The concept is not to be confused with power of attorney
Psychiatric facilities can deny patients for a myriad of reasons, such as:
1) preexisting medical conditions
2) inability to manage the patient’s medical comorbidities
3) requiring specific laboratory or ancillary testing irrespective of clinical need
4) facility issues (e.g., requiring patietns in the same room to be of the same gender)
