The initial steps include simultaneous medical and psychiatric evaluation while maintaining patient and staff safety.16 Obtain vital signs including pulse oximetry, and perform point-of-care blood glucose determination. Simultaneously assess the patient's potential for dangerous behavior, such as harming self or others or leaving the ED without medical advice; stabilize the behavior; and evaluate the chief complaint. Then, obtain a focused history; perform physical examination and mental status/-neurologic testing to identify comorbid or primary medical issues; and assess the need for hospitalization. Formulating a specific diagnosis is not as important as determining whether the patient is harmful to self or others or is unable to take care of self and needs hospitalization. Determining that an individual is suicidal and in need of protection and hospitalization, for instance, is more important than deciding whether that person has schizophrenia or psychotic depression.
The medical evaluation of patients with apparent psychiatric symptoms should be the same as for those with medical conditions17 (Table 286-3). The findings of the history and physical examination should guide laboratory testing and diagnostic inquiry. The combined findings from history, physical examination, laboratory testing, and diagnostic inquiry form the basis of the medical description of the patient.
TABLE 286-3Medical Evaluation of Psychiatric Patients ||Download (.pdf) TABLE 286-3 Medical Evaluation of Psychiatric Patients
Document behavioral changes through history.
Identify medical symptoms.
Determine medical comorbidities.
Obtain medication and drug history.
Perform physical examination.
Perform neurologic examination.
The evaluation of the patient with psychiatric symptoms in the ED is commonly termed "medical clearance." This term is a misnomer because many patients have medical problems and the term does not really mean that the patient's medical problems have been "cleared." Rather, this process identifies medical problems and their relationship to the patient's presentation. One alternative to the term "medically clear" is a discharge note that includes key features of the history, physical examination, and mental status and neurologic examination; laboratory results; discharge instructions; and follow-up plans.18 Alternatively, the term "medically stable" could be used if a specific term is required.
The medical evaluation is used to determine whether the patient has a medical condition that causes or exacerbates the psychiatric illness. The medical evaluation process is also used to identify medical illnesses or injuries that are coincident to the psychiatric illness and that need to be identified and treated prior to a psychiatric admission. The determination of a medical versus psychiatric cause for psychiatric illness or behavioral change is difficult because many psychiatric patients have medical comorbidities and some with medical illness have undiagnosed psychiatric disorders. The most frequent medical comorbidities include diabetes, cardiovascular disease, and pulmonary disease.17 If the patient with medical comorbidities needs hospitalization, be sure the psychiatric facility can provide care for concurrent medical illnesses.
MEDICAL AND BEHAVIORAL HISTORY
Medical comorbidities may produce changes in behavior. Ask specifically about fever, head trauma, immunocompetence (including malignancies and risk factors for human immunodeficiency virus infection), diabetes, pulmonary diseases, and toxic ingestions or overdose.
Obtain information about recent changes in behavior from the patient, as well as from caregivers and family members. Obtain the history of previous psychiatric illness and treatment to identify patterns of relapse. Family and social history may identify stressors in the patient's environment that are a direct cause of changes in behavior or that accentuate any responses to underlying disease. Whenever possible, corroborate all history provided by the patient, with information from family members, care providers, or law enforcement. Compare direct observations of the patient's behavior with reports from the patient's family and caregivers. This is especially important for institutionalized or group home patients whose baseline mental capacity is often unclear to ED staff.
Mental health disorders and substance abuse disorders frequently coexist.19 The syndromes associated with alcohol and substance abuse that can result in altered behavior include intoxication, withdrawal, delirium, hallucinosis, paranoid behavior, and dementia. Identify any initiation of substance abuse, changes in the patterns of abuse, and medication compliance.
Behavioral changes may be due to prescription or over-the-counter drugs, especially sedatives-hypnotics, stimulants, psychotropic agents, anticonvulsants, anticholinergic agents, angiotensin-converting enzyme inhibitors, β-blockers, corticosteroids, fluoroquinolone antibiotics, histamine-2 receptor blockers, opioids, salicylates, selective serotonin reuptake inhibitors, thiazide diuretics, and antiparkinsonian agents.20 The increasing use of serotonergic agents makes it important to check drug interactions (e.g., linezolid, tramadol) to identify serotonin syndrome as a cause of behavioral change.21 Over-the-counter analgesics or herbals and alternative medications containing salicylates, anticholinergics, antihistamines, or bromides may produce delirium or toxic psychosis.20 Alcohol and street drugs, such as phencyclidine, lysergic acid diethylamide, mescaline, amphetamines, and cocaine, can produce a toxic psychosis. Hypnosedatives, such as barbiturates and benzodiazepines, may produce a confusional state or delirium in both intoxication and withdrawal. Ask about alcohol and substance use in psychiatric presentations, even when the odor of ethanol or evidence of substance use is absent.
Psychoactive drugs are associated with a variety of hematologic and metabolic abnormalities. Clozapine, olanzapine, phenothiazines, and carbamazepine can cause neutropenia/agranulocytosis.22 Hyponatremia (sodium level <136 mmol/L) can occur with typical and atypical antipsychotics.23 Hepatotoxicity, manifested as transaminitis, obstruction, or hepatic failure, has been reported with norepinephrine-selective reuptake inhibitors more than with selective serotonin reuptake inhibitors, and also with tricyclics/tetracyclics, monoamine oxidase inhibitors, and typical and atypical antipsychotics.24 Of the herbal medications, kava-kava can cause serious hepatotoxicity, while St. John's wort has been indirectly associated with hepatotoxicity due to its effects on the P450 system of other medications.25
Perform a physical examination on every patient.25,26,27 Measure vital signs, including temperature, and oxygen saturation by pulse oximetry. Investigate abnormal vital sign values, and do not dismiss them as due to anxiety or stress. Fever is especially important, because both local and systemic infections can cause altered mental status, as can meningitis, encephalitis, and brain abscess. Neuroleptic malignant syndrome and serotonin syndrome are causes of psychoactive drug-related fever.28
Patients with abnormal vital sign values, abnormal mental status examination results, psychosis, mental retardation, or advanced age usually require a complete head-to-toe physical examination, with street clothing removed and dressed in a hospital gown. Look for signs of trauma to the head, face, and neck, and reconstruct any mechanisms of injury. In the homeless, or in those with exposure, assess for hypothermia and check the extremities for frostbite. Examine for skin rash, extremity trauma, and needle tracks. Neurologic examination typically includes an assessment of most cranial nerves, gait, mental status, and general motor function and strength. For more focused neurologic examinations, test for apraxias, agnosias, right-left disorientation, aphasias, visual field cuts, and inability to follow complex spoken and written commands. Such signs may or may not occur in association with other localizing neurologic signs, such as asymmetric reflexes, paralysis, or hemiparesis.
Table 286-4 lists signs and symptoms associated with medical causes of behavioral abnormalities. Sudden onset of major changes in behavior, mood, or thought in a previously normal patient, or definite deterioration in a patient with a chronic behavioral disorder should stimulate evaluation for an underlying medical or neurologic disorder. A sudden change in behavior, especially in a patient >45 years old, is an important indicator of a possible medical disease process. Evaluate neurologic symptoms such as fainting, dizziness, disorientation, impairment of speech, confusion, loss of consciousness, headaches, difficulty performing routine tasks, new cognitive deficits, and focal weakness.
TABLE 286-4Signs and Symptoms Suggesting Medical Cause of Behavioral Abnormalities ||Download (.pdf) TABLE 286-4 Signs and Symptoms Suggesting Medical Cause of Behavioral Abnormalities
Abnormal vital sign values
Disorientation with clouded consciousness
Abnormal mental status examination findings
Recent memory loss
Age >40 y without a previous history of psychiatric disorder
Focal neurologic signs
Important abnormalities on physical examination
MENTAL STATUS EXAMINATION
The mental status examination is conducted to understand the patient's mental state and, when combined with the history and physical examination, aids the formulation of a diagnosis and disposition. A mental status examination can help identify delirium, medical disorders, and psychiatric disorders; identify patients who are dangerous to themselves or others; and help assess patient disposition (Tables 286-5 and 286-6). A great deal of the information obtained in mental status examinations becomes evident through observing the patient's appearance, behavior, language, comprehension, and affect during the initial patient interview. However, cognitive assessment and determination of suicidal or homicidal ideation or hallucinations and delusions generally require additional questioning.
TABLE 286-5Mental Status in the ED: An Outline ||Download (.pdf) TABLE 286-5 Mental Status in the ED: An Outline
|Behavior ||What is the patient doing? |
|Affect ||What feelings is the patient displaying? |
|Orientation ||Does the patient know what is happening, where, and when? |
|Language ||Is the patient understanding and being understood? |
|Memory ||Can the patient recall historical details, recent and remote? |
|Thought content ||Is the patient reporting beliefs that make little sense? |
|Perceptual abnormalities ||Is the patient experiencing unusual sensory phenomena? |
|Judgment ||Is the patient able to make rational decisions? |
TABLE 286-6Features of Delirium, Dementia, and Psychiatric Disorder ||Download (.pdf) TABLE 286-6 Features of Delirium, Dementia, and Psychiatric Disorder
|Clinical Feature ||Delirium ||Dementia ||Psychiatric Disorder* |
|Onset ||Acute, over days ||Slow ||Varies |
|Course over 24 h ||Fluctuates ||Stable ||Varies |
|Consciousness ||Reduced or hyperalert ||Alert ||Alert or distracted |
|Attention ||Disordered ||Normal ||May be disordered |
|Cognition ||Disordered ||Impaired ||Rarely impaired |
|Hallucinations ||Visual and/or auditory ||Often absent ||Usually auditory |
|Delusions ||Transient, poorly organized ||Usually absent ||May be present |
|Body movements ||Tremor, asterixis, jerks ||Often absent ||Varies |
Important components of the mental status examination include ability to provide historical information, attention, speech patterns, language comprehension, affect and mood, hallucinations and delusions, level of cognitive functioning, degree of insight and capacity for introspection, and ability to establish a therapeutic relationship. Abnormal findings in any of the above components may suggest a medical basis for abnormal thought or behavior. Liability of affect, the need for simple questions to be repeated, irritability, disorientation, and lack of cooperation are some additional signs of medical dysfunction.
During the examination, the patient's affect or outward display of emotion should be evaluated for sadness, euphoria, and anxiety, and whether such emotions are appropriate to the current situation. This may help distinguish between cognitive disturbance induced by depressive disorders and dementia due to cerebral pathology. An examiner can draw some conclusions regarding a patient's thought processes during the patient's telling of his or her personal history. Disordered thought processes include paranoid or grandiose delusions, fixed false beliefs, and delusional denial of illness. Such beliefs should be compared with reports from family and friends. Visual hallucinations can occur in psychiatric illnesses (schizophrenia or affective disorder) but most often result from medical disease; assume medical pathology until proven otherwise. Judgment can be gained by asking the patient to describe how he or she would deal with day-to-day problems, such as finding the way home from the hospital. Judgment may be impaired in medical disease, so ask about historical evidence of faulty judgment.
Assess cognitive impairment to identify the presence of dementia or delirium. Cognitive impairment often is not detected in ED patients, despite estimates suggesting that from 26% to 40% of older ED patients are cognitively impaired.29 There are many tests of cognitive function, from simple to complex, but few have been investigated in the ED.
The Quick Confusion Scale consists of seven items and takes about 3 minutes to administer (Table 286-7; see also Table 168-3). A cut-off of ≤11 points has a sensitivity of 64% and specificity of 85% for identifying cognitive impairment.30
TABLE 286-7The Quick Confusion Scale (abnormal ≤11 points) ||Download (.pdf) TABLE 286-7 The Quick Confusion Scale (abnormal ≤11 points)
|Item ||Score |
|What year is it? ||2 |
|What month is it? ||2 |
|State short key phrase to remember; have patient repeat it immediately || |
|What time is it? ||2 |
|Count backward from 20 to 1 ||2 |
|Say months in reverse ||2 |
|Repeat key phrase ||5 |
Another self-administered screening test for cognitive function is the clock test. Give the patient a piece of paper with a circle drawn on it, and ask the patient to "place the numbers on it to make it look like a clock." After completing this task, then ask the patient to place the hands of the clock to read a time such as "10 past 11." Although there are various methods for scoring the clock drawing test, the easiest for ED use is the simplest: correct or not correct. Using a more complex 10-point scoring system, the sensitivity for dementia detection was reported as 76% and specificity was 81%. Clock test results do not appear to be affected by depression.31
The Mini-Mental State Examination is a widely used tool for assessing cognitive impairment and to follow changes in cognition over time32 but is not practical for general ED use.
Obtain laboratory testing based on abnormalities in the history and the physical examination. There is no unanimity between specialties about the need for extensive laboratory testing for all ED psychiatric patients.33,34 The psychiatric literature reports that 46% to 80% of psychiatric patients have undiagnosed medical illness,35,36 whereas the emergency medicine literature supports a selective approach to laboratory testing in the ED.37,38 Often, routine testing is a requirement of the psychiatric consultant or is part of the admission process of the psychiatric hospital.39,40 The best approach is to collaboratively establish standards for testing on a local level.
For adults with new psychiatric complaints, obtain a through laboratory evaluation including a CBC, electrolytes, liver and renal function studies, urinalysis, and possibly chest radiograph, neuroimaging, or drug and alcohol testing depending on the patient and the circumstances.
Many institutions require drug and alcohol testing for all patients with psychiatric complaints whether the patient admits to substance abuse or not. However, specific drug and alcohol testing is not clinically necessary if the patient admits to using alcohol and drugs when asked and is awake and cooperative.41 Urine drug testing and blood alcohol concentrations do not correlate with the degree of intoxication. The patient's cognitive abilities, rather than a specific blood alcohol level, should be the basis for assessment. On the other hand, patients with altered mental status without known cause need a complete evaluation including alcohol and drug testing.
One guide for the discretionary use of testing is provided in Table 286-8.41,42 Documenting items in Table 286-8 can also be used as a communication tool to psychiatrists about the ED evaluation process.
TABLE 286-8A Suggested Medical Clearance Checklist* ||Download (.pdf) TABLE 286-8 A Suggested Medical Clearance Checklist*
|Does the patient have a new psychiatric condition? ||Yes ||No |
|Is there a history of an active medical illness requiring evaluation? ||Yes ||No |
|Are there any abnormal vital signs? ||Yes ||No |
|Are there any abnormal findings on physical examination (conducted with the patient disrobed and in hospital gown)? ||Yes ||No |
|Are there any mental status abnormalities indicating medical illness? ||Yes ||No |
Advanced testing such as radiographs, electrocardiograms, and electroencephalograms should be based on the patient's clinical condition and suspicion for medical illness. CT and related brain imaging should be considered for a clear change in behavior or if an intracranial cause is suspected. The type of diagnostic imaging depends on findings from the history, mental status examination, physical examination, and differential diagnosis.