General psychiatric approach: Difference between revisions
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== | ==Background== | ||
*Be wary of diagnostic overshadowing (e.g. erroneously attributing symptoms of ''medical'' illness to psychiatric disease) | |||
**Compared to overall population, patients with mental illness have significantly higher rates of stroke<ref>Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333</ref>, CAD<ref>Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333. </ref>, DM<ref>Mai Q, D’Arcy C, Holman J, Sanfilippo FM, Emery JD, et al. (2011) Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study. BMC Med 9: 118. | |||
</ref>, cancer<ref>https://www.cdc.gov/mentalhealth/data_stats/mental-illness.htm</ref>, HIV, HCV<ref>Disability Rights Commission (2006) Equal Treatment: Closing the Gap. A Formal Investigation into Physical Health Inequalities Experienced by People with Learning Disabilities and/or Mental Health Problems. Disability Rights Commission. London.</ref> | |||
==Clinical Features== | |||
Mental Status Exam | |||
*General Appearance | |||
*Orientation and Attention | |||
*Speech | |||
*Mood and affect | |||
*Thought Patterns (process, content) | |||
*Psychomotor behavior | |||
*Insight and Judgement | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Psych DDX}} | {{Psych DDX}} | ||
==Evaluation== | |||
*Rule out medical pathology as cause or exacerbating factor for presentation | |||
{{General ED Psychiatric Workup}} | |||
===Evaluation=== | |||
*[[Sad person's score]] | |||
===ACEP Guidelines 2005=== | |||
*Class B recommendations | |||
*Routine laboratory testing is of low yield and unnecessary | |||
*Routine urine toxicology need not be performed | |||
*Pending results should not delay transfer or evaluation | |||
*Patient’s cognitive abilities, rather than specific blood alcohol level, should dictate initiation of psychiatry evaluation | |||
==Management== | |||
{{General ED Psychiatric Management}} | |||
==Disposition== | |||
==See Also== | ==See Also== | ||
[[Category: | ==External Links== | ||
==References== | |||
<references/> | |||
[[Category:Psychiatry]] |
Latest revision as of 14:37, 11 October 2019
Background
- Be wary of diagnostic overshadowing (e.g. erroneously attributing symptoms of medical illness to psychiatric disease)
Clinical Features
Mental Status Exam
- General Appearance
- Orientation and Attention
- Speech
- Mood and affect
- Thought Patterns (process, content)
- Psychomotor behavior
- Insight and Judgement
Differential Diagnosis
General Psychiatric
- Organic causes
- Psychiatric causes
Evaluation
- Rule out medical pathology as cause or exacerbating factor for presentation
General ED Psychiatric Workup
- Point-of-care glucose
- CBC
- Chem 7
- LFTs
- ECG (for toxicology evaluation)
- ASA level
- Tylenol level
- Urine toxicology screen/Blood toxicology screen
- EtOH
- Urine pregnancy/beta-hCG (if female of childbearing age)
- Consider:
- Ammonia (see Hepatic encephalopathy)
- TSH (hypo or hyperthyroidism may mimic mental illness)
- CXR (for Tb screen or rule-out delirium in older patient)
- UA (for rule-out delirium in older patients)
- Head CT (to rule-out ICH in patients with AMS)
- Lumbar puncture (to rule-out meningitis or encephalitis)
Evaluation
ACEP Guidelines 2005
- Class B recommendations
- Routine laboratory testing is of low yield and unnecessary
- Routine urine toxicology need not be performed
- Pending results should not delay transfer or evaluation
- Patient’s cognitive abilities, rather than specific blood alcohol level, should dictate initiation of psychiatry evaluation
Management
General ED Psychiatric Management
- Non-pharmacologic
- Verbal de-escalation
- Offer comforting items: blanket, meal, pillow, etc
- Quiet room
- Physical restraints (should administer medications if restraints used, as decreases restraint time)
- Pharmacologic: Goal is to calm patient without oversedation
- No history of psychosis
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
- Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
- Known or suspected underlying psychotic illness
- Continue treatment with previous antipsychotic or
- PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
- IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
- (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
- Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
- No history of psychosis
Disposition
See Also
External Links
References
- ↑ Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333
- ↑ Leucht S, Burkand T, Henderson J, Maj M, Sartorius N (2007) Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand 116: 317– 333.
- ↑ Mai Q, D’Arcy C, Holman J, Sanfilippo FM, Emery JD, et al. (2011) Mental illness related disparities in diabetes prevalence, quality of care and outcomes: a population-based longitudinal study. BMC Med 9: 118.
- ↑ https://www.cdc.gov/mentalhealth/data_stats/mental-illness.htm
- ↑ Disability Rights Commission (2006) Equal Treatment: Closing the Gap. A Formal Investigation into Physical Health Inequalities Experienced by People with Learning Disabilities and/or Mental Health Problems. Disability Rights Commission. London.