Presenting Psych Patients

[Faebinder]

I often find that providing a good presentation on the surgical/medical floors to be key in making life smooth with the attendings and seniors. I'm hoping to pick the brains of the psych experienced folks around here on what are the keys of presentation when it comes to Psych patients.

e.g.

This is a 56 y/o female with PMHx of Crohn who is here with RLQ abdominal pain for 3 days. No fever, diarrhea, vomiting, cough or bleeding.

In a psych patient... The green part is easy, just insert the history to the symptom, e.g. insert 3 past episodes of major depression. The yellow part is also easy as you put the presenting symptom, e.g. failed suicide attempt. The red part is the hardest. I'd like to hear what are the key negatives or alarming positives that attendings want to know in the classic affect and thought disorders? I would appreciate hints on psych presentations as well.

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[diosa428]

If your attending makes you present a mental status exam (mine did ALL the time), I suggest you ask him/her to present one to you at some point if you are having difficulty with it. My attending would have me start to present one, and then interrupt me at whatever point that I deviated from how he liked his MSE presented, and I would never get to finish, so the next time I would mess up on whatever part came next. It took a week before I asked him to tell me how he wanted them presented, and from there on it was smooth sailing.

 

[Anasazi23]

I often find that providing a good presentation on the surgical/medical floors to be key in making life smooth with the attendings and seniors. I'm hoping to pick the brains of the psych experienced folks around here on what are the keys of presentation when it comes to Psych patients.

e.g.

This is a 56 y/o female with PMHx of Crohn who is here with RLQ abdominal pain for 3 days. No fever, diarrhea, vomiting, cough or bleeding.

In a psych patient... The green part is easy, just insert the history to the symptom, e.g. insert 3 past episodes of major depression. The yellow part is also easy as you put the presenting symptom, e.g. failed suicide attempt. The red part is the hardest. I'd like to hear what are the key negatives or alarming positives that attendings want to know in the classic affect and thought disorders? I would appreciate hints on psych presentations as well.

Different places do it differently...

Case of a 44 year old single, Hispanic, unemployed, separated female with a history of schizoaffective disorder who presented to the ED with complaints of worsening auditory hallucinations and depressive symptoms in the context of recent medication noncompliance. The patient reports that these voices are often command in nature, and at times, tell her to "run to Iraq to help the soldiers." Further, she endorses elements of thought insertion [give example], thought broadcasting [example], and ideas of reference (feels as though various car horn noises have meaning for her).

She further endorses worsening mood over the last two weeks, characterized by poor motivation, tearfullness, poor sleep, decreased appetite with subjective 5 lb weight loss, and passive suicidal ideation with specific plan or intent.

It goes on and on....

Some include the major medical in the intro line. I do only if it's an infectious process, HIV, HEP C, etc. I don't include asthma or htn. That to me, can me mentioned later.

 

[whopper]

A lot of what the attendings want to hear has a lot to do with what the next step needs to be.

E.g. in Emergency psyche the options are

1-admit to the inpatient unit
2-discharge-nothing else
3-discharge with referral to outpatient doctor or program
4-hold for a few more hours of observation.

So the presentation the doc wants to hear factors in all the stuff to decide whether or not to commit. Then if the pt is not commitable, then if the patient is appropriate for inpt or not as a voluntary

E.g. Pt had a suicide attempt with a plan, a past suicide attempt and has enough criteria for MDD, poor sleep, low mood, poor energy, poor interests, for over 4 weeks. He has a gun at home. (easy--commit, he's going inpatient).

Then if the patient is not right for inpatient discharge with nothing or discharge with referral
E.g.: pt has enough symptoms for MDD: low energy, low mood, poor interests, poor sleep, but is not suicidal & wants outpatient treatment. His family agreed to pick him up & they agree he's not a danger to himself.

In inpatient, the game follows a logarithm that'll last a few days.
1-admission
2-first 1-3 days: This time social worker collects collateral data, you, the attending, & the treatment team observe the patient, during treatment team you try to accurately nail down the diagnosis because often times the admitting dx is not corrrect
3-usually by day 3-4 you are confident in the diagnosis, by so by then you know which is the right med to put the patient on. Just follow the medication's efficacy and side effects. Also make sure the patient is on board with your treatment plan & you address their concerns.
4-by day 4-6 the patient is on the right track & consider them for discharge if they're alright enough--otherwise keep them in the unit.
5-if they don't seem to get better you're going to have to consider for long term unit referral.

The presentation at least where I'm at should focus on what stage their in. E.g. admission--the presentation should basically be a summary of their H&P. First 2-3 days, presentation should be based on measuring how accurate the dx is based on your & the treatment team's observations..
e.g. Pt was diagnosed with Psychosis NOS, and may have had a brief psychotic disorder, but the UDS is (+) for cocaine & he's almost completely cleared up even though his antipsychotic has not yet been tapered up to an appropriate dosage.

attending-ok, we'll stop the antipsychotic. If he doesn't get worse in the next 2 days, & still gets better we'll discharge him. Let me know if anything changes after we stop the antipsychotic. Restart the antipsychotic if any sx tend to get worse.

Day 3-4: Remember Mr X? HEs the guy who got a lot better after he was on the unit and we stopped his meds because we thought it was cocaine induced psychosis? He's been off the meds now for 48 hrs and he's gotten better.

Attending: OK, its probably all from the cocaine. Let's arrange a family meeting & we need to reinforce to him that his sx were from the cocaine & he needs to lay off the stuff.

Or let's pretend it didn't go this way.

Day 3-4: Remember Mr x? He's the guy who got a lot better after he was on the unit & we stopped his meds? 6 hrs later he started responding to internal stimuli, got Haldol PRN, and is still psychotic. I don't know what happened during those hours of clarity.

Attending: When he was admitted he got hit with a lot of haldol and that clarity was from the haldol. We'll have to restart his antipsychotic and keep him on it this time. Taper up the dose appropriately.

Don't memorize any of this. At least where I'm at, you'll catch it very quickly through osmosis.

 

[worriedwell]

For most psych attendings they don't care nearly as much as surgeons and the variability is much greater depending on the setting and type of interaction you are having with the patient. In some sense, just do a brief medical model presentation as you are describing.

one thing that helps me with presenting pertinent positive and negative findings is to realize that when i'm seeing someone for the first time, i am screening for:

Dangerousness
Psychosis
Mood disorder (depression or mania)
Anxiety disorder
Drug or alcohol problem
Cognitive disorder or attentional disorder
Medical conditions that could contribute to above
Psychosocial situation that could contribute to above

So pertinent things always are (and these come up in mental status exam as well): Suicide hx, violence hx, AH/VH/Paranoia, neurovegative sxs of depression (sleep, appetite etc), sxs of mania, anxiety as in chronic worry or panic attacks, drug intoxication or withdrawal, medical hx, social situation and stressors, and dementia/delirium screen if applicable.

for many attendings it suffices to say, no sxs of mania, denies anxiety or panic, denies drugs or etoh now or in the past etc as opposed to listing all the symptoms based on dsm. but be ready to elaborate if they then inquire further.

best,
worriedwell

ps-also if you are presenting a person with symptoms of depression, you just need to r/o other things that can be associated with depression. So in that case it is vital to talk about any hx of mania, any thyroid problems, any drug problems, any recent stressors, and of course suicidal ideation in a more elaborate fashion.

but if you are describing someone with psychosis, it is important to touch on paranoia and hallucinations and negative symptoms of schizophrenia, drugs, and developmental hx.

but overall the above algorhythm is a basic outline of big areas of screening that then you can decide on how deep to describe them based on the clinical presentation.

 

[Faebinder]

For most psych attendings they don't care nearly as much as surgeons and the variability is much greater depending on the setting and type of interaction you are having with the patient. In some sense, just do a brief medical model presentation as you are describing.

one thing that helps me with presenting pertinent positive and negative findings is to realize that when i'm seeing someone for the first time, i am screening for:

Dangerousness
Psychosis
Mood disorder (depression or mania)
Anxiety disorder
Drug or alcohol problem
Cognitive disorder or attentional disorder
Medical conditions that could contribute to above
Psychosocial situation that could contribute to above

So pertinent things always are (and these come up in mental status exam as well): Suicide hx, violence hx, AH/VH/Paranoia, neurovegative sxs of depression (sleep, appetite etc), sxs of mania, anxiety as in chronic worry or panic attacks, drug intoxication or withdrawal, medical hx, social situation and stressors, and dementia/delirium screen if applicable.

for many attendings it suffices to say, no sxs of mania, denies anxiety or panic, denies drugs or etoh now or in the past etc as opposed to listing all the symptoms based on dsm. but be ready to elaborate if they then inquire further.

best,
worriedwell

ps-also if you are presenting a person with symptoms of depression, you just need to r/o other things that can be associated with depression. So in that case it is vital to talk about any hx of mania, any thyroid problems, any drug problems, any recent stressors, and of course suicidal ideation in a more elaborate fashion.

but if you are describing someone with psychosis, it is important to touch on paranoia and hallucinations and negative symptoms of schizophrenia, drugs, and developmental hx.

but overall the above algorhythm is a basic outline of big areas of screening that then you can decide on how deep to describe them based on the clinical presentation.

Thank you. Very Insightful.

 

[RaistlinMajere]

This thread is terrific. I have a follow up question regarding the initial presentation of a patient. Faebinder's question didn't include an A/P, but most attendings want this portion of the presentation, right? If yes, is there a good source for the management of psych patients? I'd like to prepare for my subI, which is a few months away. Thanks.