History

• PC + HPC
• ICE
• Screening
  • Depression → mood? low energy? no longer enjoying things you once did?
  • Risk Assessment → to self? to others? from others?
  • Psychotic Screen
    • Hallucination Screen → when under stress we can hear things that other people tend not to notice, has this ever happened to you? Have you heard voices when there is no other person around?
      • Ask about content, timing, frequency and effect on the patient.
      • Auditory most common.
    • Thought Disorder Screen → insertion (someone putting thoughts into your head?), broadcasting (others can hear your thoughts or read your mind?), withdrawal (someone taking thoughts out of your head?), passivity (someone is controlling you?).
    • Delusion Screen → any beliefs that other people find difficult to understand?
• PMH + DH
• Substance Misuse History
  • AICC → alcohol use, illicit drug use, cigarettes, caffeinated products.
  • CAGE (Alcohol) → feel need to cut down? feel annoyed by people commenting on your drinking? feel guilty about your drinking? ever drink an eye-opener in the morning to relieve the shakes?
    • CCWTNH → control, compulsion, withdrawal, tolerance, neglect, harm.
• FH
• SH
  • LOST (will help with social part of management plan)
  • Personal History (BCE) → birth, childhood, education.
  • Forensic History → ever been in trouble with the police?
• MSE (ABSEPTIC)
  • Appearance/Behaviour → general appearance, engagement, eye contact, facial expression, body language.
  • Speech → rate, tone, volume, rhythm.
  • Emotion (Mood & Affect) → mood: patient’s predominant subjective internal state described by them (what patient tells you), affect: what you observe.
  • Perception → hallucinations (auditory / visual).
  • Thoughts → flow and coherence, thought content (delusions/obsessions/compulsions/overvalued ideas), thought disorder.
  • Insight → understand what they are experiencing is abnormal.
  • Cognition → orientated in time, place and person.
  • Risk → to self / to others / from others.

Dealing with an Angry Patient

• Adjusting Communication → stay calm, speak slowly and clearly. Relaxed posture (uncross arms/legs, sit back).
• Acknowledge Anger → ‘I can see you’re quite upset by all this, can you tell me a bit more about why exactly you feel like this’.
  • Be empathetic and apologise → ‘I understand why you feel that way and I’m sorry’, ‘Is there anything we can do to help you’.
• Agitation:
  1. Safety → calm patient as much as possible, call security, move patient to safe place.
  2. Conservative Measures → turn lights on, orient the patient, see if relative present. Try verbal de-escalation, conflict resolution, positive behaviour.
  3. Last Resort → medication. Always offer oral route first (if rejected can give IM).

Investigations

• Bedside → collateral history. Questionnaires. Examination (assess physical health and risk assess). Urine Drug Screen.
  • Questionnaires → depression: PHQ-9, anxiety: GAD-7, dementia: MMSE and AMTS, OCD: Y-BOCS.
• Bloods → assess for organic causes: FBC (anaemia), U&Es (hypercalcaemia), TFTs (hypothyroidism)
• Imaging → CT/MRI.

Counselling

• Bio-Psycho-Social Model → ‘we like to take an approach that looks after you in terms of your mind, your body, and your general needs’.
  • Bio → anti-depressants, anti-psychotics, mood stabiliser, donepezil/memantine.
  • Psycho → CBT, DBT, Family Therapy, Memory Training.
    • CBT: ‘type of talking therapy that helps you manage problems by changing the way you think and behave. This can help you change negative thought patterns which will subsequently improve the way you feel.’
    • Family Therapy: ‘involves working with the whole family to support the child. It helps family members understand the disorder, improve communication, and create a supportive home environment to aid the recovery process’.
  • Social → lifestyle changes, housing, employment, education, finance.

Additional Points