The Washington Manual Internship Survival Guide (30 page)

3.
  Understanding of risks and benefits of treatment options.

4.
  Ability to manipulate information rationally and give a rational explanation for preferred treatment.

Some people add a fifth criterion, which is consistency of the choice over time, but this is more controversial.

•
  Clinical pearls:

•  Many consults to psychiatry result from patients not being adequately informed of the risks and benefits of the proposed treatment.

•  
Presence of psychosis does not necessarily mean that a patient lacks capacity
(e.g., belief that one is part of the intergalactic guard may have no bearing on understanding the risks and benefits of cardiac catheterization).

•  
Capacity is decision specific
; one may have capacity to take IV meds but not PO if one believes that all of the pills are sprayed with a poison.

•  
Capacity is time specific
. Demonstrating capacity today is no guarantee that one will be able to demonstrate capacity tomorrow should mental status fluctuate.

•  Psychiatric consultation can only help with determining if a patient lacks capacity to make a decision; the consult will not tell you who the decision-maker should be if the patient lacks capacity.

Psychosis

•
  Definition: Psychosis is a break with reality demonstrated by hallucinations, delusions, or bizarre behavior.

•
  Psychosis itself is not a psychiatric emergency. The psychiatric consult can wait until the morning. On a medical/surgical floor,
psychosis is often a symptom of delirium
, which can be a medical emergency.

•
  Critical diagnostic question: Is the patient delirious (i.e., does the patient have a fluctuating level of consciousness with altered mental status)? If so, see the section on the violent patient for further discussion of delirium.

•
  Before calling the consult, obtain the following information:

•  Key history: Age, gender, previous psychiatric treatment, nature of psychosis and symptom onset, presence of anxiety, current meds, brief general medical history and hospital course, presence of suicidal or homicidal ideas, presence of command hallucinations.

•  Key physical findings: Presence or absence of agitation, anxiety, thought disorder, bizarre behavior.

•
  Clinical pearls:

•  Visual hallucinations usually result from delirium or intoxication.

•  Auditory hallucinations are the most common form in psychiatric disorders.

•  Olfactory and gustatory hallucinations are usually seen in the aura of a seizure.

•  Tactile hallucinations can result from drug withdrawal.

•  Psychosis is a symptom, not a diagnosis; a full psychiatric interview is necessary to determine the cause and direct treatment.

•  Psychosis can be related to dementia as well as delirium. Of note, elderly dementia patients on antipsychotics have increased mortality risk; risk/benefit ratio must be examined to determine treatment.

Domestic Violence, Rape, and Psychiatric Trauma

•
  Legal reporting requirements:

•  
Physicians in every state are required to break confidentiality and report suspected cases of child abuse
to local authorities, usually called the Division of Family Services or Child Protective Services.

•  Many states also require that suspected elder abuse be reported.

•  There are no such legal requirements for spouse abuse.

•
  Rape victims should be referred to obstetrics and gynecology for collection of evidence, treatment of physical trauma, evaluation of exposure to STDs, and referred for follow-up counseling.

•
  Psychiatric consultation may help with the treatment of depression, anxiety, substance abuse, posttraumatic stress disorder, and personality disorders that are all commonly found in the victims of domestic violence and rape. Perpetrators of domestic violence also frequently have many of these problems.

•
  Before calling the consult, make sure the patient is willing to see a psychiatrist. Include the following information:

•  Key history: Age, gender, previous psychiatric treatment, nature of symptoms, presence of anxiety and depression, current meds, brief general medical history and hospital course, presence of suicidal or homicidal ideas.

•  Key physical findings: Presence or absence of agitation, anxiety, overt psychosis.

•
  Diagnosis: Questions regarding domestic abuse should be asked as a routine part of the social history in every patient.

•
  Treatment:

•  Should begin with
referral to a specific rape/domestic violence support program
if one is available locally.

•  Will depend on the patient’s individual symptoms.

•  Generally includes allowing the patient to tell and retell the story of the trauma in a safe, supportive environment so that the associated anxiety lessens over time.

•
  Clinical pearls:

•  If in doubt, call protective services regarding child abuse for more guidance.

•  Patients rarely volunteer information on being a victim of domestic violence; the first step toward helping them is to ask.

•  Never tell victims of domestic violence that they must leave their current living situation immediately. Such a proclamation could subsequently result in a lethal attack.

Withdrawal/Chemical Dependency

•
  Minor alcohol withdrawal:

•  Diagnosis:

▪  Tremors, headache, nausea, sweating, and autonomic instability occurring approximately 12 hours after the last drink and lasting up to 5 days if untreated.

▪  No hallucinations, seizures, or delirium.

•  Treatment:

▪  
Benzodiazepines
(e.g., lorazepam 0.5 to 2 mg q6-8h or chlordiazepoxide 25 mg qid) given scheduled and/or prn to keep vital signs stable, with a gradual taper over approximately 4 days. Need only to treat for objective symptoms of alcohol withdrawal. For severe withdrawal, consider giving more frequent doses of lorazepam than above depending on the clinical course, based on objective changes in autonomic tone (HR, BP).

▪  Frequent monitoring of vital signs.

▪  Adequate hydration.

▪  Adequate replacement of electrolytes, particularly potassium and magnesium, as needed.

▪  Replacement of vitamins, especially vitamin C, folate, and
thiamine
.

▪  Seizure prophylaxis in those with a history of seizures.

▪  The patient should be encouraged to allow psychiatric consultation for diagnosis and treatment of a possible chemical dependency.

•
  Major alcohol withdrawal (aka rum fits and DTs).

•  This should not result in a straight psychiatric consultation. Consultation with a medpsych service or internal medicine may be more appropriate, and such consultation may be emergent.

•  Diagnosis:

▪  See the criteria under minor alcohol withdrawal.

▪  Between 3 days and 2 weeks after the last drink, minor withdrawal symptoms become accompanied by hallucinations, seizures, or delirium. Autonomic instability worsens.

•  Treatment:

▪  Same as for minor alcohol withdrawal, but monitoring of vital signs and supportive treatment are even more important; severe cases may require transfer to the ICU.

▪  Haloperidol added to the benzodiazepine can help treat hallucinations.

▪  The patient should be encouraged to allow psychiatric consultation for diagnosis and treatment of a possible chemical dependency.

•
  Cocaine and opioid withdrawal:

•  Diagnosis:

▪  In opioid withdrawal: nausea, muscle aches, rhinorrhea, diarrhea, piloerection, and craving.

▪  In cocaine withdrawal: fatigue, agitation, increased appetite.

•  Treatment:

▪  While both conditions are unpleasant for the patient, they are rarely medically serious.

▪  Opioid withdrawal can be treated with clonidine, 0.1 mg PO tid or a methadone taper. Can treat other symptoms prn (e.g., ibuprofen for aches).

▪  The patient should be encouraged to allow psychiatric consultation for diagnosis and treatment of a possible chemical dependency.

•
  Chemical dependency:

•  Before calling the consult, make sure the patient is willing to see a psychiatrist. Include the following information:

▪  Key history: Age, gender, previous psychiatric treatment, amount of use, route of use, withdrawal symptoms, presence of anxiety and depression, current meds, brief general medical history and hospital course, presence of suicidal or homicidal ideas, presence of psychosis.

▪  Key physical findings: Presence or absence of agitation, anxiety, overt psychosis, withdrawal signs.

•  Diagnosis: Questions regarding alcohol and substance use should be asked as a routine part of the social history in every patient.

▪  Criteria revolve around tolerance, withdrawal, and inability to control use. n
If two of the CAGE questions are positive, the patient should be encouraged to allow psychiatric consultation for more definitive diagnosis. Other patients, of course, may also be appropriate for referral.

1.  Ever tried to
C
ut down?

2.  Have people
A
nnoyed you by criticizing your drinking?

3.  Felt
G
uilty about drinking?

4.  Had an
E
ye opener (morning drink) to avoid withdrawal?

•  Treatment:

▪  Support groups such as AA.

▪  Anticraving medication such as naltrexone, nalmefene, or ondansetron for alcoholism.

▪  Methadone maintenance (from specially licensed clinics) for severe opioid dependence. Suboxone is also used for maintenance treatment of opioid dependence, but is often not readily available in nonpsychiatric inpatient units due to restricted distribution.

▪  Psychotherapy aimed at relapse prevention.

▪  Treatment of comorbid depression and anxiety disorders, which are very common.

•  Clinical pearls:

▪  Sedative withdrawal has the same clinical picture as alcohol withdrawal.

▪  The shorter the half-life of the benzodiazepine (e.g., alprazolam), the more likely the withdrawal.

▪  Untreated DTs have a mortality of over 15%.

▪  Drug use often accompanies STDs, physical trauma, and other medical conditions.

GENERAL SURGERY

Key Points

•
  The following recommendations apply to almost all instances of calling for a consultation from essentially any service.

•
  Identify yourself and the patient that needs a consult and then clearly identify the questions you need answered.

•
  Give an indication of the urgency of the consult (i.e., stat, a few hours, or sometime today).

•
  Present the crucial information for the problem.

•
  State whether important radiographs have been obtained. If they are not accessible to the consultant electronically (i.e., if they were done at another hospital), state their location.

•
  State whether the patient has had a recent operation, and who performed it, or whether the patient has ever been operated on for a similar or related problem, and by whom.

•
  Time-efficient communication is crucial.

For example: Hi, this is Mike Smith. I am a medicine resident. I have an urgent consult regarding the management of a patient with a pulseless and cold right foot. The patient is Mr. Smith, his DOB is 5/5/45 and he is located in room 6443. He is a 62 y.o. diabetic male with CAD and severe PVD who …
.

Hernia

•
  
A strangulated hernia is a surgical emergency, call a consult immediately!

•  A
reducible
hernia is one that can easily return through its fascial defect.

•  An
incarcerated
hernia is one that is irreducible (impossible to push back through the fascial defect).

•  A
strangulated
hernia is one in which the blood flow of the hernia’s contents is compromised leading to necrosis of the contained structures. The signs of this are a fever, leukocytosis, hypotension, erythema of the overlying skin, or extreme pain with light palpation of the hernia.

•
  Pertinent information: Location and duration of the hernia, scar overlying hernia, patient’s surgical history, associated symptoms, status (strangulated, incarcerated, or reducible), time of patient’s last bowel movement, fever, leukocytosis, or erythema of the skin overlying the hernia. Is the patient immunocompromised?