Psychiatry Flashcards
MSE
APPEARANCE & BEHAVIOUR
cleanliness and grooming
syndromic features
presence of hallucinatory behaviours (eg talking to self; laughing incongruently)
psychomoto agitation (tics, stereotypies, odd mannerisms, tremors)
SPEECH
Spontaneous
Fluency
Rate, volume & tone
QA latency
Intonation
MOOD
euthymic
apathetic
angry
dysphoric
euphoric
AFFECT
range (constricted to labile)
reactivity (blunted or flat to reactive)
appropriateness.
THOUGHT (form and content)
flight of ideas
tangential
poverty of content
delusions (eg persecutory, referential, grandiose, somatic, bizarre)
phobias, magical thinking, thoughts of harm to self or others.
PERCEPTUAL DISTURBANCE
passivity phenomena
hallucinations
COGNITION
level of consciousness
orientation
attention
memory
INSIGHT & JUDGEMENT
acknowledgement of a possible mental health problem
judgement can be explored by recent decision making).
Depression Focussed History and MSE
2016 OSCE Station
b) Risk factors for post partum depression
Personal and family history of depression
Previous post partum depression
Personal history of chronic health problems/chronic pain
Low socioeconomic status
Partner abuse/domestic violence
Drug and alcohol abuse
Lack of social support/geographical isolation
Poor living conditions
Traumatic/difficult pregnancy or birth
Unwanted pregnancy
Baby has health issues or special needs
Diagnostic criteria for Major Depressive Disorder (Reference Tintinalli’s table)
Depressed mood
Anhedonia - lack of enjoyment
Appetite change - Weight loss or gain
Sleep disturbance/Insomnia
Fatigue/lack of energy
Feeling of worthlessness
Excessive feelings of guilt
Poor concentration
Suicide Risk Assessment (Reference Tintinalli’s table)
Established plan
Access to weapons/poisons
Previous suicide attempt
Substance abuse
Irritability/aggression/agitation
Settled finances/will
Significant mental health disorder
Disposition/Admission (Reference Tintinalli’s)
Reasons for admission:
- Risk of harm to baby
- Psychosis
- High risk suicide/Self harm
- Lack of ability to care for self
Lack of support in the home environment
Complicating medical or substance abuse
Delirium
An 85 year old woman from a nursing home is sent in by ambulance with increasing confusion and agitation for three days. She is combative and agitated.
Tips:
- lower drug doses
- use antipsychotics instead of benzodiazepines
CLINICAL FEATURES:
Acute onset
Fluctuating level of consciousness
Marked by inattention (poor concentration)
Disorder thinking
Disorientation
Hallucination and Delusions
CAUSES:
Usually precipitated by a reversible cause
Drugs:
- medication review/call pharmacy
- recent medications changes
- Culprits - anticholinergics & opioids & steroids
Withdrawal:
- alcohol and benzodiazepines
Infection:
- UTI
- Pneumoniae
- Pressure ulcers/cellulitis
Metabolic:
- hyponatremia
- hypercalcemia (undiagnosed cancer)
Trauma:
- falls
- hip fracture
- subdural haematoma
Pain:
- Urinary retention
- Constipation
Vascular:
- MI
- Stroke
PREVENTION:
*Seek and treat any precipitants
*Adequate nutrition and hydration
*Treat pain adequately
*Prevent constipation - consider regular aperients
*Medication reviews - avoid psychoactive drugs
*Review need for IV lines and catheters
*Encourage mobility
*Limit ED length of stay - try and get them to ward
*Orient the patient:
- encourage use of spectacles and hearing aids
- have clocks and calendars
- involve family and caregivers
- consistency with nursing staff
MANAGE AGITATION:
Manage is quiet area
Continuous observation with 1 to 1 nursing
Verbal de-escalation
- re-orientate
- offer food and drink
- allow to mobilise with staff if safe to do so
- recruit trusted others (family, carers) to sit with patient
Treat reversible causes for agitation
Offer oral medication for agitation
Haloperidol 0.5-1mg PO once
Add Risperidone 0.5-1mg PO or IM once
OR
Olanzapine 2.5mg PO or IM once
OR
Quetiapine 25mg PO once
Avoid chemical and physical restraint at all cost.
Physical and chemical restraint ONLY if patient safety and staff safety is compromised
Avoid Benzodiazepines:
- worsen confusion and disinhibition
- cause paradoxical agitation
- cause ataxia & falls
- cause respiratory depression
- loss of airway reflexes –> aspiration
Side effects in antipsychotics:
*Extrapyramidal side effects:
- tardive dyskinesia
- bradykinesia
- dystonic reactions
*Neuroleptic malignant syndrome
*Orthostatic hypotension
avoid in parkinsons, lewy body dementia & prolonged QTc
Managing the Aggressive Patient
Majority of patients are not bad people
There is often a reason for behaviour
VERBAL DE-ESCALATION
Prepare yourself
- stay calm
- don’t react
- be aware of non-verbal communication ‘open body language’
introduce yourself
offer a hand if safe to do so
address patient by name
Speak to the patient in a calm, empathetic non-judgemental manner
Show genuine concern and compassion
Listen - Let the patient voice their concerns
Act as ally
Explain that you are here to help and advocate on their behalf
Identify and manage the trigger for the escalation in behaviour
Identifying unmet needs that are easily corrected (e.g. inadequate pain control, hungry for food and drink)
Recruit trusted others to help (e.g. family, friends, case managers)
Provide food, drinks or other assistance as required (e.g. seating, access to a telephone, a warm blanket)
Offer oral medication to alleviate patient distress
Lay down the law and set clear limits
Show of force - involve security staff. This may persuade the patient to cooperate.
Otherwise physical restraint and parenteral chemical restraint will be required to ensure safety of the patient and staff
PHARMALOGICAL MANAGEMENT:
Oral:
lorazepam 1-2mg orally
olanzapine 10mg orally
Parenteral:
droperidol 10mg IM, repeat if needed
olanzapine 10mg IM
midazolam 5-10mg IM
RESCUE SEDATION
ketamine 5mg/kg up to 400mg IM
need to be monitored in resuscitation area - 1 to 1 nursing, cardiac monitoring, pulse oximetry and capnography
Anorexia
2022.2 Communication
interact with the parent of a child with an eating disorder.
EM Rapid Bombs ep 390,391
COMPLICATIONS:
Cardiac:
- heart failure
- arrythmias
- bradycardia
Falls/Syncope:
- orthostatic hypotension
Fractures - osteopenia
Electrolyte disturbance:
- hypokalemia (laxative abuse)
- hyponatreamia
- hypophosphatemia
- hypocalcemia
- hypomagnesia
Haematological: (starvation induced bone marrow suppression)
- Iron deficiency anaemia
- Thrombocytopenia
GI:
- dental erosions
- gastritis
- oesophagitis
- mallory weis tears
- pancreatitis
Gynaecological:
- Ammenorrhoea
- infertility
Psychiatric:
- depression
- anxiety
- suicidality
- obsessive compulsive disorder
Neurological:
- peripheral neuropathy
Treatment goals:
- restore health body weight
- psychosocial support and mental wellbeing
Outpatient management is GP led and takes a multidisciplinary approach with psychologist and dietician
Create a personalised eating disorder treatment plan
- supplements (multivitamins, thiamine, calcium, vitamin D)
- close monitoring for re-feeding syndrome
- blood tests
- weight
Psychological treatments:
- family based therapy
- cognitive based therapy
Psychological support for caregivers - large psychological burden for caregivers
- refer to support group agencies
Refer to a psychiatrist if suspect an associated psychiatric disorder
HISTORY:
Excessive weight loss
Restrictive eating/dieting
Excessive exercise
Fear of weight gain
Laxative, diuretic or weight loss medications
Binge eating/purging
Associated psychiatric conditions
- depression
- anxiety
- suicide
- psych admission/medications
Body image distortion
Unusual eating habits/rituals
- eating away from others
- prolonged meal times
- cutting food into small pieces
Collateral history is important because patient is often in denial or has poor insight into disorder
Physical complaints:
syncope/fainting/light headedness
palpitations/chest pain/SOB
ankle swelling
weakness
pathological fractures
amenorrhoea
abdominal pain - acute pancreatitis
Psychiatric complaints:
- depression
- anxiety
- suicide
- self harm
- previous psychiatric admissions
- psychiatric medications
- substance misuse
Social history
- friends
- sports/hobbies
- drugs/alcohol
- school
- home life
EXAMINATION:
Height
Weight
Calculate BMI
Temperature (hypothermia)
HR (bradycardia, dysrhythmias)
Lying and standing BP (orthostatic hypotension)
Tachycardia on minimal exertion
brittle hair, hair loss, lanugo hair
dorsal hand abrasions
dental erosions
facial purpura, conjunctival haemorrhage
parotid and salivary gland hypertrophy
INVESTIGATIONS:
Bhcg
ECG - bradycardia, QT prolongation, arrythmias - atrial ectopics
BSL - hypoglycaemia <3mmol/L
FBC - anaemia, thrombocytopenia, leukopenia
Iron studies - iron deficiency
LFT’s - hypoalbuminaemia
Lipase - acute pancreatitis
UEC - K+ <3, Na+ < 130, raised urea
CMP - Phospate < 0.5, low Ca+, low Magnesium - monitor refeeding syndrome
Bone density scan if >6months
ADMISSION:
- Body weight <75% expected
- Failed outpatient management - ongoing weight loss
- Acute psychiatric emergency (suicidality, self harm)
- Pregnancy
- Hypothermia Temp <36
- Bradycardia HR 40
- Hypotension BP <90/60,
- Orthostatic hypotentio >20mmHg drop
- Dehydration
- Signs of heart failure
- Severe electrolyte abnormalities
REFEEDING SYDROME:
In the first week of refeeding, monitor vital signs and (in high-risk patients) cardiac rhythm, and look for signs of oedema, heart failure and a deteriorating mental state.
Signs:
- Hypophosphataemia
- Hypokalaemia
- Congestive Cardiac Failure
- Peripheral Oedema
- Rhabdomyolysis
- Seizures
- Haemolysis
HEADS ED
HOME:
- Who lives at home
- How does your family get along with each other?
*Child Protection Issues, Family Violence
EDUCATION:EMPLOYMENT:
How is your school attendance?
How are your grades?
Are you working?
ACTIVITIES & FRIENDS:
What are your relationships like with your friends?
What do you do for fun?
Optional probe: Bullying
DRUGS & ALCOHOL
- do you use drugs or alcohol
SUICIDE:
Do you have any thoughts of wanting to kill yourself?
How would you do it?
When would you do it?
Have your thoughts of suicide changed?
EMOTIONS, THOUGHTS, BEHAVIOURS
How have you been feeling lately?
Do you ever get any bad thoughts that you can’t get out of your head?
Do you get into any trouble with parents, police, school etc.?
DISCHARGE OR CURRENT RESOURCES:
Do you have any help or are you waiting to receive help (counselling etc)?
Suicide
male gender
ethnicity - indigenous, refugee,
low socioeconomic status
unemployment
lack of social supports
drug and alcohol dependence
chronic pain/chronic disease
elaborate plan in place
multiple previous attempts
access to weapons - guns, poisons
prepared - settled wills, finances
relationship/marriage breakdown
“SAD PERSONS”
S - sex - male
A - age <19 or > 45
D - depression
P - previous attempts
E - excess alcohol and drug use
R - rational thinking loss
S - social supports lacking
O - organised plan
N - no spouse
S - sickness
Prepare - settled finances and wills
Relationship breakdown
Access to weapons - guns, poisons
Chronic pain/chronic disease
Unemployment
