History

•  Ask open-ended? s re: thoughts, feelings, personal relationships; drug use; prior hospitalizations/psych hx; psych medications; physical/sexual abuse

•  Suicidal/HI: Access to weapons, plan, prior SI/HI or attempt; command hallucinations

•  Depression, mania

•  Psychosis: Delusions, hallucinations, bizarre behavior, disorganized speech

Findings

•  Abnl VS; appearance, mental status exam

•  Head-to-toe exam: E/O trauma, pupils, nystagmus, thyroid, pulm/cardiac/abdomen, skin

•  Neuro: CNs, DTRs, motor, sensory, cerebellar, asterixis, gait, catatonia (consider NMS)

Evaluation

•  There is no data to support routine use of lab testing in psych pts whose H&P exclude significant medical illness

•  βhCG (all women reproductive age), consider ECG & psych med levels (ie, Li)

•  Tox: If concern for unreported drug abuse or ingestion (ie, APAP)

•  Psychiatry consult: If ? needed for hospitalization, suicide/homicide attempt, uncertain @ risk of danger to self/others

•  Other labs: If concern for “organic” d/o or required for psych hospital: CBC, Chem 7, LFTs, UA, TSH, ammonia, CXR

•  More thorough w/u is necessary for new onset psych Dx: Consider RPR, CT head, LP, EEG

Treatment

•  Treat any underlying medical illness

•  Meds:

•  Haldol (IM/IV), risperidone (PO/IM), ziprasidone (IM), olanzapine (PO/SL/IM); side effects: ↑ QT, akathisia, dystonia

•  Lorazepam/diazepam (PO/IV/IM): preferred for drug-related agitation; avoid in the elderly

•  Physical restraints: Soft/leather (1–4 point), posy: Use as temporizing measure in conjunction w/ pharmacologic tx & 1:1 sitter

Pearls

•  Signs suggestive of “organic disorder” age >40 w/ no prior psych hx, abnl VS, recent memory loss, clouded consciousness

•  Engage family member/friends/partners whenever possible

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