Butler OMH-HCSD Behavioral Medical Screening and Assessment ppt

LSU Health Care Services Division Managing The Behavioral Health Patient in LSU-HCSD Presentation To The Mental Health Improvement Task Force By Michael K. Butler, MD, MHA, CPE October 24, 2006 LSU Health Care Services Division Behavioral Health Medical Screening Exam The process of determining whether a serious medical illness exists that makes admission to a psychiatric facility unsafe or inappropriate. LSU Health Care Services Division Goals  Standardized Medical Screening For the Behavioral Health Patient  Appropriate Laboratory Testing  Understanding EMTALA Rules  Standard Transfer Protocols LSU Health Care Services Division Goals  Safe and Appropriate Patient Disposition  Adequate Documentation of Psychiatric and Co-existent Medical Diagnoses Communication of Findings To Psychiatric Unit and Facility  Accurate  Minimize the time to disposition of the cost of the screening exam patient  Minimize LSU Health Care Services Division Issues for PMSE  Is the patient impaired or not?  Is there a medical cause for the suspected behavioral health problem?  Do they have an unstable medical condition?  Is the person suicidal, homicidal, or gravely impaired? LSU Health Care Services Division Types of Patients 1--Behavioral Health Problems Only (BHO)  Type 2--Behavioral Health and Stable Medical Condition (BH and SMC)  Type 3--Medical Problem Masquerading As Behavioral Health (MC Not BH)  Type 4--Behavioral Health Problem with Unstable Medical Condition (BH and UMC)  Type LSU Health Care Services Division Pitfalls Negative Counter Transference Intoxication and Withdrawal Fundamental Attribution Error LSU Health Care Services Division Differential Diagnoses Delirium Dementia Psychosis LSU Health Care Services Division Delirium  Intracranial  Systemic Disease Disease with CNS Involvement  Substance  Toxic Abuse Withdrawal Exposures LSU Health Care Services Division Dementia  Gradual Loss of Cognitive Abilities  Clear Level of Consciousness  Non-Fluctuating over The Day  Primary Deficit—Impaired Short Term Memory LSU Health Care Services Division Psychosis—Organic Causes  Age  New greater than 40 Diagnosis of Psychosis Vital Signs  Abnormal  Recent Memory Loss Consciousness  Clouded LSU Health Care Services Division Vital Signs  Blood  Pulse Pressure  Temperature  Oxygenation Assessment LSU Health Care Services Division Key Historical Information      Age of Onset of Behavioral Symptoms Past Medical History Past Psychiatric History Recent Illness, Hospitalization, Surgery or Trauma Suicidal or Homicidal Ideation (Thoughts and Plans)    Access To Firearms Drug or Alcohol Use Hallucinations (Visual, Auditory, or Tactile) LSU Health Care Services Division Physical Findings      Vital Signs Appearance (Grooming) Level of Attention Affect  Eye—EOM and Fundoscopic Neck Exam—Nuchal Rigidity and Thyroid Enlargement   Eye Contact Chest Exam-Pneumonia, CHF, or Arrhythmias Stigmata of Cirrhosis Skin—Cold Clammy, Hot and Sticky   Speech Signs of Head Trauma   LSU Health Care Services Division Mental Status Exam Orientation Mood Affect Memory Language Attention Calculation Abstraction General Information Judgments Thoughts LSU Health Care Services Division Brief Mental Status Examination LSU Health Care Services Division Laboratory Testing Current Regimen  CBC       TFT (TSH) RPR or VDRL PT/PTT Chest X-Ray EKG Blood Alcohol Level  Complete Metabolic Profile   Urinalysis Urine or Serum BHCG  Urine Toxicology Screen LSU Health Care Services Division Criteria For Laboratory Testing  Age  New Greater Than 40 Onset Psychiatric Complaint Vital Signs Physical Findings Neurological or Mental Status  Abnormal  Abnormal  Abnormal Exams LSU Health Care Services Division MADFOCS Differentiation Between the Organic and the Psychiatric Patient  Memory  Activity  Distortion  Feelings  Orientation  Cognition  Some Other Findings LSU Health Care Services Division MADFOCS Mnemonic LSU Health Care Services Division Sensitivity of Detecting Medical Issues in the Behavioral Health Patient  History—94%  Physical  Mental Examination—50% Status Examination—72%  Laboratory Assessment--<50% LSU Health Care Services Division Disposition of Patients  Type 1—BHO: Referral to In-Patient or OutPatient Psychiatric Care Type 2—BH and SMC: Referral to In-Patient or Out-Patient Psychiatric Care with medical consultation as needed.   Type 3—MC not BH: Admission to Medical Service for treatment of Medical condition Type 4—BH and UMC: Admission to Medicine for Stabilization of medical condition and then transfer to psychiatric service  LSU Health Care Services Division Suicide Risk Factors: SAD PERSONS S Sex-Males are at greater risk for completion while females attempt more often.  A Age: Bimodal distribution with increased incidence among adolescents and people older than 50 years  D Depression or other psychiatric illness LSU Health Care Services Division Suicide Risk Factors—SAD PERSONS        P Previous Attempts E Ethanol or Other Drug Use R Recent Stressor: loss of a loved one, job, or significant life change S Social Support Lacking: Lack of interaction with friends or therapist O Organized Plan: One should inquire about the specific plan, if a patient has formulated one. N No Spouse: similar to lack of social support. Single people are at increased risk. S Sickness: Any chronic medical illness LSU Health Care Services Division References Lemonick, MD, David M., “Conducting Medical Clearance of the Psychiatric Patient”, Emergency Medicine, March, 2006, pp. 10-19.