This document provides information on evaluating patients presenting with psychiatric complaints. It discusses that medical illnesses are missed in 4% of cases due to deficiencies in history and physical exams. Common missed illnesses include infections, pulmonary, thyroid, and neurological disorders. Hypoglycemia and hypoxia should be considered in all new psychiatric presentations. A thorough history, physical exam, and lab work is important to identify any underlying medical conditions.

1. EPT MLP Training
Gil,M PA-C

2.  8th leading cause of death for all ages
 3rd leading cause of death in adolescents
 In the past 20 years suicide killed more
people than HIV and AIDS
 90% of patients who commit suicide suffer
from a diagnosable mental illness
 About 40-60% of those who die by suicide
are intoxicated at the time of death
 10% of patients who attempt suicide will re
attempt within one year

3.  Current suicidal ideation
 Intent/ Plan
 Hx of Suicide Attempts
◦ Date, circumstances, and method
 Hx of Mental illness
◦ Intensity of current depressive symptoms
◦ Current treatment
◦ Psychotic Symptoms
 Auditory command hallucinations, external control, and religious pre
occupation
 Drug and alcohol use
 Concurrent medical illness
 Past or Present hx of Violence/Aggression
 Recent life stressors
 Current living situation

4.  Make sure patient is fully undressed prior to
entering room
 Patients belonging should be taken and stored
 He/She should be checked for any pills, drugs,
weapons, sharp objects ect.
 Observe patient from doorway or discuss with
nursing interaction, ensure that patient is not
threatening
 Pt should have sitter at bedside if he/she has
active SI complaint or are a danger to themselves

5.  Only 13% of surveyed psychiatrists perform a physical
exam on their inpatients
 Inspect head for trauma or prior neurosurgery
◦ Signs of basilar skull fracture
 Ocular exam
◦ Pinpoint pupils – narcotics, organophosphates or clonidine
◦ Dilated pupils – stimulant or anticholinergics, withdrawal from
sedatives, narcotics or post anoxic injury
◦ EOMS- impairment seen with Wernicke’s encephalopathy or space
occupying lesions
◦ Nystagmus-
 Vertical (brain stem lesion), Wernicke’s encephalopathy or congenital
 Horizontal or rotatory nystagmus suggests drug or more commonly
alcohol toxicity
 PCP intoxication – blank open eye stair with roving gas, nystagmus and
dilated pupils

6.  Neck exam- meningeal signs or thyroid
enlargement
 Chest exam – auscultate for PNA, PTX, CHF,
COPD, Heart Murmur – valvular heart disease
(endocarditis)
 Abdominal exam – obstruction, perforation,
hemorrhage, or infection in the abdominal cavity,
enlarged liver (jaundice or asterixis)
 Inspect skin for rashes, Kaposi sarcoma or
petechiae, Track marks
 Neuro exam is most frequent deficiency in
charts, perform basic neuro exam depending on
suspicion of medical diagnosis

7.  Fever in combination with psychiatric
complaint is concerning for intracranial
infection of systemic illness
 Hypoglycemia and hypoxia are common
causes of agitation and AMS

8.  Hypoglycemia may be responsible for up to
10% of altered behavior in ED patients
 UDS is unlikely to change managements,
patients typically will admit to drug or etoh
use if being seen for a psychiatric complaint
 Labs including blood chemistries, CBC, UA,
toxicology and alcohol have only a 20%
sensitivity of detecting a medical disorder
 History alone has 95% sensitivity

9.  CXR – unnecessary in most patients unless hx
of cough, tachypnea or low pulse ox, more
liberal use in the elderly
 CT Head – worrisome headache, focal neuro
exam, at risk for chronic subdural (dialysis,
anticoagulated, alcoholic, seizures, falls)
 LP – Patients with fever, meningismus or
immunocompromised

10. Points
•Sex
•Age (<19 or > 45)
•Depression or Hopelessness
•Previous suicide attempts or psychiatric care
•Excessive alcohol or drug use
•Rational thinking loss
•Separated, divorced or widowed
•Organized or serious attempt
•No Social Supports
•Stated future intent
Score 6-8: Full Emergency Psychiatric Eval/Treatment
Score 9 or greater: Immediate Psychiatric Hospitalization
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11.  Compliance with psychiatric medications
 Social Support
 Involvement in a religious group
 Being a parent
 Positive coping skills
 Adequate treatment of chronic pain or
substance abuse
 Adequate followup

12.  Patient and Complaint Dependent
 Attempted Suicide
◦ CBC, BMP
◦ Etoh, UDS, APAP, Salicylate level
◦ EKG
◦ Preg
 At a minimum
◦ Most will require Istat8, UDS, etoh, preg

13.  PERS- Consult for voluntary admissions, ED
Consults
 CSB- Social Worker who will find placement
for ECO/TDO patients
 ECO- Emergency Custody Order
 TDO- Temporary Detention Order
◦ Medical- Patients who are deemed not able to
refuse treatment or lab work because of medical
condition

14.  4% of the time a medical diagnosis is missed
 Deficiencies in history and physical examination accounted
for the vast majority of illness
 Most common are infection, pulmonary, thyroid, diabetic,
hematopoietic, hepatic and CNS disease
 Hypoglycemia, Hypoxia and Thyroid disease should be
considered in all patients with new onset psychiatric
disease
 Serum Sodium > 160 mEq/L is associated with AMS
 Serum Sodium < 115 mEq/L produces confusion, coma
and even seizures
 Hypercalcemia < 14 mg/dl can cause lethargy and mental
status change
◦ Malignant neoplasms and hyperparathyroidism account for the
vast majority of hypercalcemia

15.  Disturbance of consciousness occurring over a
short time and affecting attention, with
impairment in other cognitive function
 May be disoriented to time or place but not to
person
 Perceptual disturbances including
misinterpretations, illusions or hallucinations
 Disturbances develop abruptly and fluctuate
 Drug toxicity or withdrawal accounts for up to
30% of all cases of delirium
 UTI is one of the most common causes of
delirium in the elderly

16.  Effective loss of reality testing, a disturbance
of thought processes and consequently,
changes in behavior
 Disrupts perception and disorganizes
thinking to a degree that interferes with
social interactions
 Suspect medial etiology in new cases of
psychosis, especially if patient in > 40 y.o

17.  Major depression diagnosis requires
alterations in mood, psychomotor activity,
and cognition
 15% of patients with major depression
commit suicide

18.  Persistently elevated, expansive or irritable
mood
 At least three of the following: inflated self
esteem or grandiosity, decreased need for
sleep, increased talkativeness, flight of ideas,
easy distractibility, increased activity or an
excessive quest for pleasure
 Mood disturbance is severe enough to
markedly interfere with job performance and
personal relations

19.  Complaints of anxiety, nervousness, panic or
stress
 Sleep disturbance, irritability, difficulty
concentration, easy fatigue, restlessness, and
muscle tension
 If a patient has a panic attack after age 35
and there is no clear cut psychologic
precipitant, suspect a medical cause,
hyperthyroidism, hypoxia, hypoglycemia, or
drug toxicity.

20.  Sensation of bugs crawling under skin-
associated with cocaine or speed use
 Bugs on the walls – alcohol withdrawal
 Visual Hallucinations are strongly associated with
a medical pathology
 Seizure prior to presentation suggests postictal
sate or nonconvulsive status epilepticus
 Palpitations, tremor and weight loss suggests
hyperthyroidism
 Headache suggests CNS tumor, meningitis or
chronic subdural hematoma

21.  Late age (over 40) of onset of a new behavioral
symptom
 No past medical history of psychiatric illness
 Sudden onset of altered behavior
 Presence of a toxidrome
 Visual Hallucinations
 Known systemic disease with new onset behavior
change
 New Medication
 Altered behavior temporally related to a convulsive
seizure
 Abnormal vitals
 Disorientation
 Clouded consciousness

22.  Very Uncooperative patient
◦ 5 MG IM Haldol + 2 MG IM Ativan + 50 MG IM
Benadryl, one syringe
◦ OR 10mg Geodon IM
 Somewhat cooperative
◦ PO dosing of above Rx

23.  Acute behavior changes in elderly are at risk
for adverse outcomes
 Common sequela to infection or other
disease
 Nearly 20% of elderly patients brought for
emergency psychiatric eval may be suffering
from a drug reaction
◦ Review BEERS Criteria
 http://chpw.org/resources/Providers/Beers_Criteria.pdf