Download A General Approach to the Psychiatry Consultation/Liason

Practical Approach to the Psychiatry Consultation/Liaison Patient
David C. Belmonte, M.D.
Disclaimer: This outline is intended to provide a framework for assessment of the C/L patient.
It is by no means exhaustive. Ultimately, assessments should be individualized.
1. Establish the reason for referral.
a. What is the consult question? What is the “real” question? Often it requires some
detective work to figure out what motivated the consult.
b. If vague, contact the resident and clarify the question the primary team wants
answered.
c. Be professional, courteous, and tactful when interacting with the primary team.
Part of professionalism is working with our medical and surgical colleagues and
treatment them the same respect we expect to receive from them when we are
uninformed about their area of specialization.
2. Before seeing the patient, determine the interview objectives, and strategize how to
structure the interview to accomplish them.
a. Can the presenting signs and symptoms be clustered into psychiatric syndromes?
b. What data is necessary and pertinent to help differentiate diagnoses?
c. Determine onset, duration, and precipitants of symptoms.
d. How debilitating are the symptoms to the patient? Do they interfere with selfcare, role-functioning, or occupation?
e. Attempt to understand the person behind the patient. How does the acute
presentation fit within the patient’s longitudinal history of psychiatric distress
(e.g., personality features, coping strategies, history of trauma, psychological
awareness, psychosocial stressors, support network)?
3. Psychiatric Syndromes and Consult Tasks
a. Depression
i. Suicidal ideation
ii. Neurovegetative sxs (“SIGECAPS”)
iii. MDD vs. Adjustment D/O vs. Mood D/O Due to General Medical
Condition
iv. Rating scales (e.g., Hamilton, Beck, Geriatric Depression Scale)
b. s/p suicide attempt
i. Suicide risk assessment (i.e., risk factors vs. protective factors)
ii. Circumstances of attempt: Does the story make sense? Did the patient
arrange to be rescued?
iii. Does the patient regret being saved?
iv. If the patient currently denies suicidal ideation, what is different now?
What does the patient have to look forward to?
v. What are the family’s views on patient’s risk for self-harm? Do they feel
comfortable with patient’s discharge to home?
c. Anxiety
i. Primary Anxiety D/O vs. Adjustment D/O vs. medical cause (e.g.,
dyspnea secondary to COPD)
ii. Fear of dying
iii. Fear of the unknown
iv. Loss of control
d. Capacity
i. Task specific
ii. Ability for patient to appreciate situation, to discuss options, to understand
consequences, and to demonstrate a rational decision-making process
e. “Agitation”
i. Specify behavior.
ii. Assess risk for self-injury.
iii. Assess risk for harming others (e.g., history of violence).
f. Psychosis and Mental Status Change
i. “VITAMIN CDE” (vascular, infectious, trauma, autoimmune, metabolic,
iatrogenic, neoplastic, congenital, degenerative, endocrine)
g. Cognitive Changes
i. Level of consciousness/attention
ii. How long has the impairment lasted?
iii. Importance of collateral information from family and caregivers
1. Condition of home environment
2. BADLs and IADLs
3. Exploitation
iv. Dementia vs. Delirium vs. Dementia+Delirium vs. Dementia vs.
Pseuedodementia vs. Depression+Dementia
v. For delirium, determine underlying cause. There may be latency in
clearing of mental status, even after cause is treated.
vi. Bedside neurological exam
vii. Bedside cognitive testing (e.g., MMSE, MOCA, CLOX)
h. Somatoform and Pseudoseizures
i. Ally with the patient and provide empathy.
ii. Validate that physical symptoms are causing significant distress.
iii. Good news approach- “Medical badness” ruled out or equivocal
iv. What is the degree of patient’s psychological insight?
i. Substance Abuse/Dependence
i. Withdrawal protocol
ii. Assess commitment to abstain from substance use.
4. Chart Review
a. Hospital admit note
b. Outpatient psychiatry notes
c. PES visits
d. Inpatient D/C summaries (medical and psychiatric)
e. Vitals
f. Current medications and prns administered in last 24-72 hours
g. Labs (TSH, B12, comp, CBC, U/A, U.cult, pregnancy screen)
5. Patient Interview
a. Respect the patient’s right to privacy and inquire about preference for having
family in the room during the interview. Having a family member present can be
very helpful.
b. Establish rapport. Often starting with questions about the patient’s general
medical condition is comforting to the patient.
c. Utilize active listening techniques.
d. Combine use of open and close-ended questions.
e. Be aware of non-verbal communication conveyed by the patient and yourself.
f. Quality and duration of interview may be limited by medical illness, patient
cooperation, and interruptions due to medical procedures.
6. Collateral history
a. Family
b. O/P providers
7. Neuroimaging
8. Medical problem list
a. Are there any medical conditions that would interfere with potential psychiatric
interventions, or require modifications in these interventions?
i. Liver failure
ii. Kidney failure
iii. Drug-drug interactions
iv. Diabetes
v. Hyperlipidemia
vi. Seizure history
9. Safety
a. Suicide risk
b. Risk of harming staff
c. Risk of elopement
d. Need for sitter
10. Biopsychosocial formulation and multiaxial diagnoses
11. Disposition issues
a. Does the patient require inpatient psychiatric admission?
b. Is the patient safe to return to current home environment?
c. What type of social support is present?
d. What is the plan for outpatient follow-up?
12. Relay findings and recommendations to primary team.