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Psychiatry – Expert questions Evaluation a) History b) Physical examination c) Mental state examination d) Investigations EH EH EH IH Emergency Department Screening Assessment Targeted History Focus on precipitating causes and circumstances that brought the patient to the emergency department. It may be necessary to elicit information from multiple sources such as family, friends, or ambulance personnel. Other key topics include previous psychiatric treatment, seizure disorders, polysubstance abuse, and any recent suicidal attempts including possible ingestions. Focused Physical Examination Perform a thorough physical examination, including neurologic assessment. Complete vital signs are essential. Look for physical clues to the source of an altered mental status, such as evidence of head injury, drug use, or toxidromes. Assess the patient for adverse consequences of his or her behavior such as malnutrition or dehydration. Mental Status Examination It is important to document the mental status examination in patients presenting with psychiatric emergencies. The mental status assessment should probe for global functioning, thought disorders, mood disorders, and personality disorders. Global Functioning Assess the patient for general orientation (person, place, time, reason for visit), memory (short and long term), judgment, and concentration. Thought Disorders Assess the patient for abnormal thought content such as hearing voices, experiencing command hallucinations, or having paranoid thoughts. Mood Disorders Assess the patient for evidence of depression or mania. Compare the appropriateness of the patient's stated mood with his or her overt affect. Look for clues such as emotional lability or unbalanced emotional extremes. Personality Disorders Try to assess whether the patient's current behavior is an acute psychiatric event that represents a decompensation in his or her normal functioning or a representative sample of a maladaptive pattern of behavior derived from an underlying socially inappropriate personality matrix. Screening Laboratory Tests The following studies are often helpful in the evaluation of patients presenting with psychiatric emergencies: Electrolyte panel with glucose Pulse oximetry Toxicology screen Liver function tests Computed tomography (CT) scan of the head Electrocardiogram (ECG) Thyroid function tests The Psychiatric mental state examination: The psychiatric evaluation addresses several dimensions of mental processes that are briefly discussed below. (LOABAAMMTPI) Level of Consciousness. Patients are described as o alert, o lethargic, o stuporous, or in o coma. Orientation. This has four dimensions: person, place, time, and situation. o Does the patient know who he and others in the room are? o Does he know their names and roles? o Does he know where he is—the place, city, state, country? o Does he know the year, season, day, and date? Appearance and Behavior. Close observation of the patient during the interview will provide important information. o How is the patient dressed and groomed? o How is the patient's personal hygiene? Does the patient make and sustain eye contact? o Does the patient answer questions promptly and fully? Are there areas of questioning that the patient avoids or tries to deflect? o What is the patient's body language? o Is the patient fidgeting or unusually still? o What is the patient's tone of voice, volume, and speech rhythm? Attention. This is the ability to stay on task and follow the course of a conversation and interview avoiding distractions. o Attention deficits are the hallmark of confusional states and delirium and should alert the clinician to the possibility of a metabolic disorder. o Tests of serial 7s, serial 3s (subtract 3 sequentially, starting at 20), and attempting to spell "world" backwards are tests of attention. o Always consider the patient's level of education in interpreting these tasks. o A nonverbal task is the tap-no-tap test. Have the patient tap his or her hand twice when you tap once; if you tap twice they are not to tap. Affect. This is the more transient state of emotion, which varies from minute to minute and day to day, depending upon the setting and types of social and personal interactions in which a person is engaged. Affect is the clinician's assessment of emotion and is assessed by facial expression, tone, and modulation of voice and specific questions about how the patient feels. Affect is also measured by considering intensity and range of expression. Affective states include o happy, o Sad, o angry, o fearful, o worried, and o wary. Mood. Mood is the sustained affective state of the patient: how they feel. It is more like the tidal flow of emotion than the waves of affect. Mood is classified as normal, depressed, or elevated. Mood should be assessed, by asking the patient, how his or her mood has been over the last 2 weeks. Other questions used to evaluate mood include questions regarding how the patient feels about his or her life, the patient's thoughts of the future, the patient's confidence in his or her abilities, and the patient's hopes, and the intensity of these feelings. If depression is suspected, it is mandatory to inquire about suicidal thoughts or plans. Depressed patients may show blunted affect with little range. Memory. This is the ability to register and retain material from previous experience. Memory is a complex phenomenon. It is usefully classified as immediate recall (registration), short- and long-term memory. o Immediate recall is the ability to register items presented. Short-term memory is the ability to recall the registered items within 5 to 10 minutes. o Long-term memory is the ability to recall events from the more distant past from days to years. o Specific tests of immediate recall and short-term memory are included in the MMSE. Shortand long-term memory is evaluated while taking the history. Find out what the patient is really interested in (such as politics, sports, cooking, etc.) and ask them, specific detailed questions about it, questions that demand specific quantitative, rather than vague qualitative answers. Thought. This is how the brain communicates consciously with itself. Thought has several dimensions. o The content of thought is what the patient is thinking about. Is it appropriate to his or her situation and a reasonable perception of the world? o The sequence of thoughts is also important. How are they linked one to the next? Can the patient digress and get back to the original point? The logic a person uses to connect events and explanations should be evaluated. What is the nature of cause and effect in his or her life? What are the reasons he gives for seeking care? o Insight is the ability to look at one's self and situation with comprehension and understanding. Lack of insight into the nature or consequences of behaviors or thoughts is an important clue to mental illness. o Judgment is the ability to make reasonable assessments of the external world and choices between alternative actions. How are decisions made? How does the patient evaluate alternatives? How are potential benefits and risks considered? Perception. This is a global term for the way in which a person experiences the world through the senses. Distortions of perception can be symptoms of either neurologic or psychiatric disease. o Hallucinations are sensory experiences perceived only by the patient, not by an observer. They may be auditory, visual, tactile, gustatory, or olfactory. Auditory hallucinations are particularly common in psychosis, Visual hallucinations are more common in delirium. Gustatory and olfactory hallucinations are common in partial seizure disorders (temporal lobe epilepsy). o Illusions are the incorrect perception of objects seen by both the patient and the observer. These are particularly common with sensory impairment such as visual loss. o Structural perception is the ability to place objects and shapes in relation to one another. It can be tested by having the patient copy interlocked pentagons (MMSE) or perform clock drawing. Intellect. Intellect is generally held to be an innate brain faculty, though it is difficult to separate deficits of intellect from deficits of education. The clinician must know the patient's educational and literacy level in order to properly evaluate his or her intellect. Culture greatly influences tests of intellect and it is hazardous to make assessments across cultures. There are several dimensions of intellect. o What is his or her information level? Does he know about important local, national, or international events? What are his or her sources of information? o Calculations, the ability to manipulate numbers are tested by simple and gradually more complex arithmetic tasks. o Abstraction is the ability to see general principles in concrete statements. Abstractions are tested by asking the patient to interpret proverbs, for example, "people in glass houses shouldn't throw stones" = "don't criticize others for things you have probably done yourself." Interpretation at the simplest level, for example, "they would break the windows," is indicative of a concrete thinking and a deficit in abstract thinking. Remember that proverbs are culturally bound and may not be recognizable to people from different cultural backgrounds. o Reasoning is the ability to solve problems involving simple logical sequences. o Language is what one brain uses to communicate with another brain. It is tested in the interview and by having the patient follow both written, verbal instructions and write a sentence (MMSE). Assess the patient's vocabulary and the complexity of the patient's spoken language. o Other dimensions of language are fluency of speech, body language, facial expression, and other nonverbal forms of communication; all should be thought of as language. Organic brain syndrome DIS H Delirium, dementia, amnesia, and certain other alterations in cognition are subsumed under more general terms such as mental status change (MSC), acute confusional state (ACS), or organic brain syndrome (OBS). The term organic brain syndrome is used to distinguish changes in cognitive/behavioral functions due to physical (organic) causes from those due to psychiatric (functional) causes. Organic brain syndrome is conceptually useful to the practicing emergency physician by highlighting a sizable list of diagnoses to be considered before a patient with abnormal mentation and/or behavior is presumed to solely have a psychiatric illness. Organic brain syndrome can be divided into 2 major subgroups: acute (delirium or acute confusional state) and chronic (dementia). A third entity, encephalopathy (subacute organic brain syndrome), denotes a gray zone between delirium and dementia; its early course may fluctuate, but it is often persistent and progressive. The final common pathway of all forms of organic brain syndrome is an alteration in cortical brain function. This condition results from (1) an exogenous insult or an intrinsic process that affects cerebral neurochemical functioning or (2) physical or structural damage to the cortex. The end result of these disruptions of function or structure is impairment of cognition that affects some or all of the following: alertness, orientation, emotion, behavior, memory, perception, language, praxis, problem solving, judgment, and psychomotor activity. Delirium Delirium is an acute organic brain syndrome, characterised by sudden onset (hours or days) of disordered attention and arousal - a reduced ability to focus, sustain or shift attention. It may be accompanied by disturbances of cognition, psychomotor behaviour and perception. It has a fluctuating course and lucid intervals may occur. There are three main clinical categories of delirium: Hypoactive: Easily missed or misdiagnosed as depression or fatigue. Quiet, passive, withdrawn, drowsy, can’t concentrate. Hyperactive: Not missed. Irritable, vigilant, restless, agitated, has insomnia. Mixed with fluctuations between hypo-active and hyper-active: the most common type of delirium. Delirium can be misdiagnosed as dementia or depression. Use the Confusion Assessment Method (CAM) tool. Presence of (1) and (2) and either (3) or (4) is required to firmly diagnose delirium: (1) Acute onset, fluctuating course; and (2) impaired attention, impaired focus of concentration (initiating, maintaining, shifting focus at will); and either (3) confusion or any impaired cognition; or (4) altered consciousness: alertness/activity Etiology of delirium and other cognitive disorders. Disorder Possible Causes Intoxication Alcohol, sedatives, bromides, analgesics (eg, pentazocine), psychedelic drugs, stimulants, and household solvents. Drug withdrawal Withdrawal from alcohol, sedative-hypnotics, corticosteroids. Long-term effects of alcohol Wernicke-Korsakoff syndrome. Infections Septicemia; meningitis and encephalitis due to bacterial, viral, fungal, parasitic, or tuberculous organisms or to central nervous system syphilis; acute and chronic infections due to the entire range of microbiologic pathogens. Endocrine disorders Thyrotoxicosis, hypothyroidism, adrenocortical dysfunction (including Addison's disease and Cushing's syndrome), pheochromocytoma, insulinoma, hypoglycemia, hyperparathyroidism, hypoparathyroidism, panhypopituitarism, diabetic ketoacidosis. Respiratory disorders Hypoxia, hypercapnia. Metabolic disturbances Fluid and electrolyte disturbances (especially hyponatremia, hypomagnesemia, and hypercalcemia), acid-base disorders, hepatic disease (hepatic encephalopathy), renal failure, porphyria. Disorder Possible Causes Nutritional deficiencies Deficiency of vitamin B1 (beriberi), vitamin B12 (pernicious anemia), folic acid, nicotinic acid (pellagra); protein-calorie malnutrition. Trauma Subdural hematoma, subarachnoid hemorrhage, intracerebral bleeding, concussion syndrome. Cardiovascular disorders Myocardial infarctions, cardiac arrhythmias, cerebrovascular spasms, hypertensive encephalopathy, hemorrhages, embolisms, and occlusions indirectly cause decreased cognitive function. Neoplasms Primary or metastatic lesions of the central nervous system, cancer-induced hypercalcemia. Seizure disorders Ictal, interictal, and postictal dysfunction. Collagen-vascular and Autoimmune disorders, including systemic lupus erythematosus, Sjögren's syndrome, immunologic disorders and AIDS. Degenerative diseases Alzheimer's disease, Pick's disease, multiple sclerosis, parkinsonism, Huntington's chorea, normal pressure hydrocephalus. Medications Anticholinergic drugs, antidepressants, H2-blocking agents, digoxin, salicylates (chronic use), and a wide variety of other over-the-counter and prescribed drugs. Delirium always has an organic cause. Pathologic mechanisms are complex and are thought to involve widespread neuronal or neurotransmitter dysfunction. There are four general causes: 1. Primary intracranial disease 2. Systemic diseases secondarily affecting the central nervous system (CNS) 3. Exogenous toxins 4. Drug withdrawal History For patients with delirium, attempt to obtain a current and past history from other sources, including prehospital workers, family or friends, and past medical records. Look specifically for street drug, alcohol, and medication use; preexisting endocrine disorders; and recent activities that may have resulted in exposure to toxins or environmental injury. Ask about prior psychiatric illness and similar episodes of confusion in the past. Physical Examination General appearance (eg, unkempt, tattooed, and/or malnourished) may suggest the possibility of drug or alcohol abuse. Look for track marks. Smell for alcohol, the musty odor of fetor hepaticus, or the fruity smell of ketoacidosis. Icterus and asterixis point to liver failure with an elevation of the serum ammonia level. Agitation and tremulousness suggest sedative drug or alcohol withdrawal. Close attention to vital signs is essential and easy to overlook in the setting of extreme behavioral difficulties in a delirious patient. Fever may point to infection, heat illness, thyroid storm, aspirin toxicity, or the extreme adrenergic overflow of certain drug overdoses and withdrawal syndromes (in particular, delirium tremens). Extreme hyperthermia (with pinpoint pupils) may be seen in pontine strokes. In patients with a rapid respiratory rate, consider diabetic ketoacidosis (ie, Kussmaul respiration), sepsis, stimulant drug intoxication, and aspirin overdose. In patients with a slow respiratory rate, consider narcotic overdose, CNS insult, or various sedative intoxications. A rapid pulse rate is seen in patients with fever, sepsis, dehydration, thyroid storm, and various cardiac dysrhythmias and in overdoses of stimulants, anticholinergics, quinidine, theophylline, tricyclic antidepressants, or aspirin. Patients with a slow pulse rate may have elevated intracranial pressure, asphyxia, or complete heart block. Calcium channel blockers, digoxin, and beta-blockers also may produce altered mental status and bradycardia. Blood pressure elevation is common in delirium because of resulting adrenergic overload. In patients with acute altered mental status and severely elevated blood pressure, check the ocular fundi for arteriolar spasm, disc pallor, papilledema, flame hemorrhages, and exudates. These are all signs of malignant hypertension. Even with these changes, the patient may be alert and minimally symptomatic. In pregnant patients with a diastolic pressure greater than 75 mm Hg in the second trimester or greater than 85 mm Hg in the third trimester, consider preeclampsia (ie, hyperreflexia, edema, proteinuria). In patients with hypertension and bradycardia, consider an elevated intracranial pressure (Cushing reflex). A brief bedside neurologic examination, including mental status testing, is an essential part of the workup of organic brain syndrome and altered mental status when a rapidly treatable cause, such as hypoglycemia or narcotic overdose, is not immediately apparent. The Mini-Mental Status Examination (MMSE) is a formalized way of documenting the severity and nature of mental status changes. A score of less than 24 suggests the presence of delirium, dementia, or another problem affecting the patient's mental status and may indicate the need for further evaluation. Investigations: Laboratory studies may be helpful for ruling in or ruling out specific diagnoses that cause delirium or a dementialike presentation. Many of these tests may not be immediately available to the ED physician, such as vitamin B-12 levels, Venereal Disease Research Laboratory (VDRL) test, and thyroid function studies. Oxygen saturation and, in some cases, ABG with a carbon monoxide level are helpful. CBC count, electrolytes level, blood glucose level, BUN level, and creatinine level should be checked. In older patients, consider vitamin B-12 and folate levels. Consider calcium level, magnesium level, and liver function tests (LFTs), including serum ammonia, prothrombin time (PT), and activated partial thromboplastin time (aPTT). Consider VDRL and/or fluorescent treponemal antibody absorption (FTA-ABS) test to help rule out neurosyphilis (see cerebrospinal fluid [CSF] studies below). Urinalysis When alcohol, drugs, and/or toxins are suspected, consider the following: Serum ethanol, salicylate, acetaminophen, carbon monoxide, and other specific drug or toxin levels as indicated Comprehensive drug analyses of blood and urine Such toxic screens are generally not helpful in the acute setting unless turnaround time is rapid. In a suspected endocrine emergency, the following are required: A bedside fingerstick blood glucose determination followed by serum glucose and serum acetone Thyroid-stimulation hormone (TSH), possibly thyroid panel Serum cortisol Serum calcium, phosphorus, and parathyroid levels In suspected CNS infection, the following may be ordered: Lumbar puncture may be done for CSF studies, including cryptococcal antigen or India ink prep, and VDRL. CT scan of head should be done before lumbar puncture to rule out toxoplasmosis or abscess, especially in patients with HIV who present with headache. Imaging Studies A head CT scan without intravenous (IV) contrast should be obtained if CNS infection, trauma, or a cerebral vascular accident (CVA) is suspected. A CT scan is excellent for detecting acute hematomas and most subarachnoid hemorrhages (SAH) but is most accurate early in the course. Follow-up lumbar puncture may be needed to rule out SAH. Other Tests An ECG may be performed to search for myocardial infarction or atrial fibrillation with rapid ventricular response. Low voltages, as seen in hypothyroidism and pericardial effusion, may give a clue to the etiology. Look for tachycardia, widened QRS, or prolonged QT interval, which suggest tricyclic overdose.