Physical illness in psych pt Flashcards
Approach to a physically ill patient (steps)
History Physical Exam Differential Diagnosis Special Investigations Collateral Immediate, Medium, Long term management
Name the risks of overlooking a physical illness
Emergency room setting
Serious and reversible causes may be missed e.g. meningitis Transference and CT issues High morbidity and mortality Vulnerable patients Litigation
Name the risks of overlooking a physical illness
Emergency room setting
Serious and reversible causes may be missed e.g. meningitis Transference and CT issues High morbidity and mortality Vulnerable patients Litigation
Who should we worry about wrt physical illness in psych pts
- Late onset or sudden onset
- Known underlying medical condition
- Abnormal vitals
- Fluctuation of symptoms
- Atypical presentation e.g. VH; OH; TH
- Absence of personal/family hx
- Illicit substance use
- Medication use
- Treatment resistance/ adverse reactions
Which condition is the most dangerous?
Delirium/acute confusional state
Which condition is the most dangerous?
Delirium/acute confusional state
Delirium DSM criteria
A disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment).
The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception).
The disturbances are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple aetiologies
Delirium DSM criteria
A disturbance in attention (i.e. reduced ability to direct, focus, sustain and shift attention) and awareness (reduced orientation to the environment).
The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability or perception).
The disturbances are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple aetiologies
Specifiers for delirium according to DSM 5
Hyperactive delirium: level of psychomotor activity increased, may be accompanied by mood lability, aggitation , and/or refusal to co-operate with medical care
Hypoactive delirium: decresed level of psychomotor activity that may be accompanied by sluggishness, lethargy, may approach stupor
Mixed level of activity: normal psychomotor activity even though attention and awareness are disturbed. Activity level may fluctuate
Management of delirium
Treat the underlying cause!
Supportive management: ABCs; hydration; nutrition; restore electrolytes
Continuous orientation, limit stimulation (quiet)
Severe agitation: short-acting benzodiazepines
Behavioural disturbance: LOW dose antipsychotics (haloperidol; risperidone)
Often multiple causes
Management of delirium
Treat the underlying cause!
Supportive management: ABCs; hydration; nutrition; restore electrolytes
Continuous orientation, limit stimulation (quiet)
Severe agitation: short-acting benzodiazepines
Behavioural disturbance: LOW dose antipsychotics (haloperidol; risperidone)
Often multiple causes
What is important when taking the history of the patient
Onset
Symptom cluster
Co-morbid medical conditions
Past medical; surgical and psychiatric hx
Substances
Systemic enquiry
Baseline level of function ? Functional decline
What is important during the physical exam?
Abnormal vital signs: Temp; BP; HR and RR Level of consciousness ? fluctuates Evidence of systemic illness: CNS HIV Organ systems Substance abuse
Which investigations could you do?
Guided by clinical picture
Cost considerations
Basic screen: WCC; Na; K; Cr; RPR
Consider toxicology screen
NB: Geriatric patients: Urine dipstix, CMP, TSH, B12
Specific conditions: e.g. HIV – consider LP and imaging
3D-CAM Scale: 3 minute Confusion assessment method: 1. acute of fluctuating course and 2. Inattention and either 3. Disorganised thinking or 4. Altered level of consciousness Marcantanio E et al Ann int Med 2014;161(8) : in press
What are the treatment considerations?
✔ No medical illness: proceed with MHCA and psychiatric Mx
Medical illness underlying symptoms:
Medication sensitivities e.g. EPSE’S
Drug-drug interactions
Pharmacodynamics and pharmacokinetics
Short-acting benzodiazepine e.g. lorazepam
Both: Collaborative approach (C/L team)
