The physically ill patient Flashcards
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 TO WORRY ABOUT
- 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
THE MOST DANGEROUS CONDITION
Delirium/ Acute confusional state
DELIRIUM: CRITERIA DSM 5
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
What characterizes hyperactive delirium?
level of psychomotor activity increased, may be accompanied by mood lability, aggitation , and/or refusal to co-operate with medical care
What are the features of hypoactive delirium?
decresed level of psychomotor activity that may be accompanied by sluggishness, lethargy, may approach stupor
What is mixed level of activity in delirium?
normal psychomotor activity even though attention and awareness are disturbed. Activity level may fluctuate
What is the 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 do take on the history
Onset
Symptom cluster
Co-morbid medical conditions
Past medical; surgical and psychiatric hx
Substances
Systemic enquiry
Baseline level of function ? Functional decline
Examination
Abnormal vital signs: Temp; BP; HR and RR
Level of consciousness ? fluctuates
Evidence of systemic illness:
CNS
HIV
Organ systems
Substance abuse
Investigations
- 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
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)
How does the lifespan of individuals with chronic psychiatric illnesses compare to the general population?
Individuals with chronic psychiatric illnesses typically die 25 years earlier than the general population.
What are the major causes of death in individuals with chronic psychiatric illnesses?
The major causes of death include:
- Cardiovascular diseases (60%)
- Respiratory diseases
- Infectious diseases
