Psychiatry

Case Author: Anthony Huffman, Class of 2021

Content Reviewer: Dayle Ostapiuk - UBC Psychiatry Resident, UHNBC

Case Objectives

Identify what type of information is important to gather before seeing a patient in the ED for a psychiatric consult.
Clarify the role and expectations of a clerk in a patient's interaction with the healthcare system.
Explain the components of a psychiatric consult.
Demonstrate an approach to writing admission orders for Psychiatry.
Demonstrate an approach to writing a SOAP note when rounding on Psychiatric patients on the wards.

Typical Scenario:

You’ve done a few psych shifts on the adolescent unit w/ Dr. D, but now you’re on call for Psych in emergency, it’s 5pm, and you call switchboard to find out which attending is on call for psych. They tell you it’s Dr. S and connect you to him...

“Hi yeah I’ve got a good one for you in emerg, the patient is in the quiet room and RCMP is watching them, why don’t you go check in with the psych liaison nurse to get some background on them. Then you can see the patient if you feel comfortable, or we can see them together…”

You say you’re “keen to see them first but are worried because it’s your first emergency psych consult.”

Dr. S says “Look, you’ll be fine. I've already eye-balled them and you can’t mess them up worse than I can fix them. Just slow down, be compassionate and use a structured approach to the history, you got this.”

You say “okay boss, I’ll call you when I’ve got an idea of what is going on.”

Objective 1: Preparing for a psych. consult

You’ll want to check in with the psychiatric liaison nurse. They can most easily be found down the hallway to the right of Trauma 2, past the double doors and in the office to the right. Otherwise they may be somewhere in the ED core. From them, you’ll get a brief history and you may get a stack of previous consults and notes giving you some useful background information (prev. diagnoses, treatments and admissions). At UHNBC, the patient’s psych EMR (eg. Synapse) is not available to you, but it is to the PLN. Despite this, it’s worth it to quickly review Powerchart for any previous consults etc. Also be sure to review the ER note completed by the ER physician.

You get down to emergency and check in with the Psych. Liaison Nurse. The PLN and the RCMP explain:

“He’s 54, RCMP were called by his sister for concerns that over the last week he had been threatening co-tenants in his apartment complex, slipping notes under doors and causing a ruckus. I wasn’t able to get much of a history from him, he seems quite withdrawn, but he says he’s not depressed or suicidal and just wants the voices to stop bothering him while he’s at home. The ER note is here, and the Emergency Room Physician (ERP) has already ‘formed’ him once”.

Unfortunately she tells you:

“This patient moved here from Alberta 5y ago and doesn’t have any previous documentation with Northern Health!”

Objectives 2 and 3: Your role as a clerk; How to perform a consult

Typically, by the time you are seeing the patient in the ED, they have already been through triage, seen an emergency physician, most likely have seen the PLN, and are now seeing you. Depending on their presentation, they may already have had a Mental Health Act Form 4 filled out by the ERP which means they are not allowed to leave the hospital, or else the RCMP have the authority to bring them back. There will most likely be documentation pertaining to their previous medical history, as well as the triage note filled out by the ER physician for you to review. You are fortunate on psychiatry to have ample time to spend with the patient and your job is to perform a psychiatric consult

A note on safety

From a safety standpoint, if the patient has not been certified and has been brought in by RCMP, RCMP are required to remain present for your interview until the patient is certified. If the patient was brought in by RCMP and an ER physician has already certified them, the RCMP are free to leave. Inform your preceptor if that is the case as they may choose to conduct the interview with you present. Your attending or the senior resident that you are working with is required to lay eyes on the patient to deem them as suitable for medical student assessment. Ask security to be present outside of the room if you still feel worried. This goes for all years of experience.

Based on the above patient history, this sounds like there could be an element of psychosis...

Practice thinking about a differential diagnosis

[click here for an example DDx for psychosis]

Primary Psychosis:

Schizophrenia spectrum: 1d ← Brief psychotic d/o→ 1mo ← Schizophreniform→ 6mo ← Schizophrenia →
Schizoaffective – depressive or bipolar type

Secondary Psychosis

Bipolar D/O I
Major Depressive D/O w psychotic features
Post-partum depression w psychosis

Substance induced – acute intoxication or withdrawal (withdrawal is a medical emergency and must be flagged as such)

Psychosis due to another medical condition (rule out delirium, head injuries, recent suicide overdose – residual effects)

Catatonia (specifier)

Other: eg. Delusional d/o

Unspecified

Neurocognitive Disorder

**Be sure to discuss the nuances of differential diagnoses with your preceptors as well as the residents you will work with**

Performing a consult

To prepare, you grab some Progress Note sheets and write out the headings for the sections you will be covering in your interview with the patient.

What follows is the result of your interview with relevant headings discussed in a separate column:

After you have written your consult note, you think about the differential, commit yourself to a management plan, and then happen to see Dr. S in the ED.

You: "Hey Dr. S, I've finished seeing the patient and can review whenever you're ready to hear it".

Dr. S: "Go for it, what do you think is going on?"

Impression

Although the entire consult is important, your impression statement is a useful opportunity to practice delivering a concise overview of your patient. Some attendings may want this first, others may want to hear the entire consult from start to finish, simply ask what they would prefer. Oftentimes there is so much that comes out in the consult that you’ll want to read from your notes, but it is a useful exercise to see how well you can recall the HPI without referring to them.

When giving a summary statement like this, it can be helpful to organize it like this:

Identification and risk factors for your suspected diagnosis; key clinical findings on interview and mental status exam (pertinent positives and negatives); your working diagnosis/differential

Example Impression statement: Practice summarizing this case now.

Identification and risk factors: 54M w/ a 1st degree FHx of suicide and ?psychotic disorder who was BIB-RCMP for:

Key clinical findings: a worsening of long-standing auditory and tactile hallucinations with delusions of thought insertion and reference that has resulted in disruptive behaviour in community and on exam he is of flat affect and alogia. Working diagnosis is schizophrenia spectrum disorder but alternate Dx may include delusional disorder.

Often you’ll find preceptors are hesitant to commit to a diagnosis immediately. There is a tendency to have diagnoses pending and allow the truth of the matter to present itself over the course of an admission. You may also notice that some preceptors seem to favour some diagnoses over others. For example, one psychiatrist may “see” bipolar while another “sees” borderline personality more frequently. The diagnosis is often elucidated further on hospital admission with extensive assessment and collaboration from community resources including collateral.

Recommendations and Plan

It can be helpful to think through the ADDAVID acronym to come up with your plan regarding necessary investigations and management.

Note: Investigations mainly serve to rule out organic causes for the presentation. Treatment will often be subject to preceptor preference. It’s useful to try to become familiar with which medication to choose. It can be helpful to familiarize yourself with first line agents and then ask a preceptor why they chose the medication they did if it differs from guidelines.

Example Recommendations and Plan: Practice this now.

Admit? - This patient is psychotic, we should discuss admission to 3NE, attempt voluntary admission followed by involuntary admission if necessary.

Diagnosis, Diet, Activity, Vitals - include this in your Admissions orders

Investigations?

Routine psych. investigations such as: CBC, electrolytes, renal function, glucose, TSH, B12 and a liver panel seem prudent.
Consideration could be given to a urine drug screen if substance-induced psychosis is high on the differential. Consideration to serum alcohol, serum salicylates, serum acetaminophen if recent overdose or need to rule out intoxication.
For delirium, one of the most common causes is a UTI – do a urine dip with urinalysis with culture and sensitivity as it would be unfortunate to label someone as psychotic if a medical source for the hallucinations is readily available.

Remember to do a serum or urine beta-HCG for appropriate patients.

Drugs?

Offer antipsychotic therapy, eg. quetiapine starting dose 50 mg/day (target 300-600 mg/day) orally once daily or divided twice daily.
- Note: If you are starting an antipsychotic, additional monitoring is required: ECG, waist circumference, height, weight, cholesterol panel, HgbA1C (think about whether you are going to give them metabolic syndrome due to the antipsychotic treatment), extended electrolytes (often patients won’t tell you they have not been eating due to paranoia around food – Mg/Ca/Phos helps rule out potential for re-feeding syndrome).
- Think about previous drugs: Was the patient taking clozapine per Pharmanet? What about lithium? Valproate? Any medication that has a potential for toxicity at high doses, should have a level drawn.
  - This also helps the psychiatrist the next day decide whether to restart a medication at a particular dose or wait and monitor levels. E.g. If a patient misses clozapine for more than 48 hours, they have to restart the titration process back to their formal level.

Together you and Dr. S you go in to see the patient. Dr. S asks a few more questions, discusses the necessity of admission to 3NE, the patient doesn’t want to stay. You leave the quiet room.

Dr. S: "I agree with your assessment of psychosis, probably schizophrenia and it's amazing that this patient has avoided treatment and hospital admission for this long! I agree that admission is necessary, the patient is not coping in community anymore. We'll need to complete a 2nd Form 4. We'll start him on olanzipine. Could you to please write the admission note and dictate your consult while I fill out the second Form 4…”

Always ask a preceptor why they chose the medication they did, this is good learning about common treatments you will see in the future. Note there is a TON of variability between preceptors.

Objective 4: Writing admission orders

ADDAVID works well but remember to include their Form status (x1, x2), and spend some time thinking about PRN management (eg. physical/chemical restraints if necessary, and seclusion)

You grab a brown Physician Orders sheet and put some patient ID stickers on it, you write:

You place the orders with the ER chart at the front nursing station and then you grab the phone and dictate a stellar consult note.

There is nothing brewing in the ED terms of psych. cases so Dr. S sends you home and says he will call you back to the hospital if anything interesting comes in. (Un)luckily, nothing else comes in that night and you get to enjoy a quiet evening at home...

Objective 5: Rounding on a patient and writing a SOAP note

Subjective: how they’re doing/sleeping/eating/energy, discuss their reason for admission/symptomatology, how they’re tolerating treatment (improvement vs. side-effects). Discuss complaints/requests and passes.

Objective: VS (often not done very frequently), new labs, MSE (eg. ASEPTIC)

Assessment: 1-2 sentences summarizing patient profile (age, M/F, race, occupation, marital status, significant characteristics) and diagnosis (+/- DDx, course/prognosis, treatment, tolerance)

Plan: List by diagnosis or problem (medication strategy, planned tests, social work issues, discharge plans)

The next morning you’re working with your usual attending, Dr. D. on 3NE, and you’re delighted to see that she just so happened to receive your patient from last night's handover from Dr. S. This means that you’ll be following this patient on 3NE every day!

You see a few patients w/ Dr. D and the patient's 3NE psych. nurse. You’re essentially playing the role of scribe (sometimes you'll lead the check-in), writing basic points in SOAP note format on the patient chart in the Physician Notes section.

You guys then decide to check-in with your new admit from last night. You grab the patient’s chart/binder from the nursing station on the rack, and then you go chat with that patient’s psych. nurse who says they’re ready to go in when you guys are ready (sometimes you’ll have to wait for the patient’s nurse).

You write the following SOAP note while your preceptor leads the conversation:

Well done! You’ve assessed a patient, formulated a management plan, admitted them, and then rounded on your patient.

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