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Last updated on 21 Jul 2014 at 11:55 AM (ED04)
Agitated and combative patient
A 68 year old NZ European man, with no fixed abode, presents under police escort to
the Emergency Department agitated and aggressive. He has presented on previous
occasions as intoxicated on alcohol, sedated and non-confrontational. He has also
sometimes presented with physical symptoms that can’t be medically explained
with the hope of acquiring an overnight stay in hospital. However, on this
presentation he has threatened to punch you and the nursing staff when you discussed
the need for him to stay in the Emergency Department for further investigations.
Applied Science for Medicine
Anatomy of the brain
Pathophysiology of delirium and dementia
Microbiology of herpes simplex virus
Role of drug intoxication and withdrawal in altered mental states
Awareness of nutritional deficiencies and how this may compound certain
presentations e.g. delirium tremens
Pharmacology of haloperidol, olanzapine, rispiridone, benzodiazepines
Clinical and Communication Skills
History from an agitated patient; elicit a collateral history; assess risk factors for
delirium
Perform a general examination, as complete as is possible; recognise drug withdrawal
and intoxication
Differential diagnosis of the aggressive patient, delirium
Indications for CT head, MRI brain, lumbar puncture
Perform capillary glucose level, measurement of blood pressure, lumbar puncture
Interpret full blood count, electrolytes, liver function tests, blood glucose level,
calcium, thyroid function tests, vitamin B12/folate, toxicology screen, pathology
report on cerebrospinal fluid (CSF), chest X-ray, syphilis serology, short synthacen
test
Management of the challenging patient: pharmacological and non-pharmacological
Awareness of high mortality rates with delirium tremens and the medical treatments
required for this
Role of security staff, levels of observation and de-escalation measures
Role of liaison psychiatry, social worker, nurse
Understand how medically unexplained physical symptoms can present
Personal and Professional Skills
Deescalating an aggressive situation
Self-care: personal safety
Decision-making capacity
Best interests principle
Assent and consent
Legal aspects of compulsory assessment and treatment, Mental Health Act, Right
7(4) of the Health and Disability Commissioner’s Code of Rights
Hauora Māori
Cultural safety in examining an agitated person
Access to cultural resources in an Emergency Department
Ethnic disparities in 'homelessness', mental disorder and alcohol/drug misuse
Population Health
Epidemiology of delirium/acute confusion state, schizophrenia, substance abuse,
substance withdrawal, herpes simplex virus, meningitis
Homelessness: reasons, support programmes, discrimination
Conditions to be considered relating to this scenario
subdural haemorrhage, psychosis of any cause,
Common
hypoglycaemia, hypoxia, hypo/hypernatraemia, urinary
tract infection, hypercalcaemia, hypocalcaemia,
concussion, vitamin B12/folate deficiency,
hypothyroidism, delirium tremens, Wernicke's
encephalopathy, acute coronary syndrome (STEMI,
NSTEMI and unstable angina), intoxications,
extradural haemorrhage
cerebral tumour, tertiary syphilis, meningitis,
Less common but
encephalitis, subarachnoid haemorrhage
'important not to miss'
Whipple's disease, uraemic encephalopathy, hepatic
Uncommon
encephalopathy, Addison's disease