Handbook of Consultation-Liaison Psychiatry

3. The Why and How of Psychiatric Consultation

Hoyle Leigh

CONTENTS

3.1 Vignette

3.2 The Nature of Psychiatric Consultation

3.3 The Consultation Procedure

3.3.1 Receive a Consultation Request

3.3.2 Talk to the Referring Physician and Clarify the Consultation Request

3.3.3 Determine the Scope of Consultation

3.3.4 Review the Chart

3.3.5 Interview the Patient

3.3.6 Obtain Collateral Information

3.3.7 Diagnose the Consultation: The Syndrome, the Patient, the Environment

3.3.8 Provide Diagnosis and Recommendations

3.3.9 Consultation Interventions

3.3.10 Follow-Up

3.4 Computerized Psychiatric Consultation Database

3.1 Vignette

A consultation request was received by fax. The request sheet simply had the patient's name and ward number and the statement, "Behavioral problem. Please evaluate." When the consultant called the requesting physician, she said, "I don't really know what the problem is, but the nurses seem to be upset about the patient. The patient just had a myocardial infarction but is doing OK. I think he may be a little depressed, though, because he is so quiet." In the patient's chart the night nurse had written that the patient was observed crying in the middle of the night. Upon interview, the consultant was able to diagnose a recurrent major depression.

3.2 The Nature of Psychiatric Consultation

Specialty consultations are requested to obtain expert opinion in diagnosing and treating conditions that fall in the specialty area. As psychiatry deals with a vast area of human experience including cognition, emotion, and behavior, it is often difficult to know the exact reason for a referral, as the above vignette illustrates. Psychiatric consultation, like any other consultation, is not the primary reason for the patient's hospitalization or contact with the health care system, and not a few patients may be surprised that a psychiatric consultation has been requested. Primary physicians may also be reluctant to request a psychiatric consultation because of the perceived stigma. Therefore, requesting a psychiatric consultation on a patient requires a certain amount of motivation on the part of the referring physician. This motivation is often generated by a strain in the health care unit consisting of the doctors, the nursing staff, and allied professionals. Common causes of such strain are patients' anxiety, communication difficulties, or behavioral problems, and administrative/legal requirements.

While some psychiatric consultations are generated at the patient's request, most arise out of discomfort on the part of one or more health care staff members, and recognizing this discomfort or strain is an essential part of a successful consultation. It is the consultant's job to ameliorate the strain so that the health care personnel can proceed to provide medical care without impediment.

As discussed in Chapter 2, the consultant serves two masters: the requesting physician (consultee) and the patient. The primary role of the consultant is to provide expert advice to the consultee so that medical/surgical treatment can be successfully rendered. A secondary role is to provide direct psychiatric care for the patient with the consultee's agreement.

The psychiatric consultant is often the face of psychiatry in the general hospital. It is through the consultant that the nonpsychiatric physicians form an impression about psychiatry, and, it is hoped, learn psychiatric approaches and techniques. The educational function of the consultant psychiatrist, as discussed in the previous chapter, is an integral part of the practice of consultation-liaison psychiatry.

3.3 The Consultation Procedure

3.3.1 Receive a Consultation Request

Most health care institutions have formal mechanisms for requesting a consultation, such as a computerized request form or a written request, delivered by fax, email, or telephone. Informal requests may also be made either by telephone or in person. While informal consultations, especially when urgent, are often attended to, it is a good idea to insist on a formal consultation request as well.

3.3.2 Talk to the Referring Physician and Clarify the Consultation Request

Consultation requests are often vague and sometimes misleading (as in the vignette at the start of this chapter), usually because the consultee lacks the vocabulary of psychiatry. The consultee is aware of the discomfort of the strain caused by the patient, but has difficulty putting it into words. Thus, it is critical that the consultant seek out the consultee, usually by phone, and ask for additional information about the consultation, particularly what the consultee would like from the consultant. It is a good idea to ask the referring physician to be sure to let the patient know to expect a psychiatric consultant, and, if possible, to introduce the consultant to the patient.

3.3.3 Determine the Scope of Consultation

The consultant should be able to determine the probable scope of the consultation after speaking with the referring physician, that is, whether it is an emergency management of an agitated or acutely suicidal patient; a comprehensive evaluation of the patient in assisting with diagnosis; or a focused consultation about a specific question, such as the patient's ability to sign out against medical advice or to consent to a surgical procedure.

Even though the question asked by the consultee may sound focused and straightforward, at times the consultant can facilitate the medical treatment through a comprehensive understanding of the patient and facilitation of communication; for example, a patient may decide to remain in the hospital rather than sign out against medical advice after a discussion between the patient and the physician that was arranged by the consultant.

In general, the narrower the scope of the consultation, the quicker should the consultant respond to the referring physician.

3.3.4 Review the Chart

The patient's chart should be reviewed prior to seeing the patient. The recent progress notes and nurses' notes should provide information about the patient's recent and current status. Medication orders, and more specifically the medications actually administered, should be reviewed, especially for any recent additions or changes that might contribute to the patient's changed mood or mental status. Laboratory and imaging findings should be reviewed for possible metabolic/structural causes of the psychiatric syndrome, as well as to determine which additional lab tests may be indicated.

Talking with the patient's nurse can yield important information not only about the patient but also about visitors and patient's interactions with the staff. Furthermore, talking with the nursing staff members allows them to discuss their impressions of the patient and to report any difficulties they may be having in patient management. Nurses appreciate a doctor who is interested in their input. Their tolerance for a patient's deviant behavior will increase when the consulting psychiatrist shows interest. This alone may influence patient-nurse interactions for the better.

3.3.5 Interview the Patient

The consultant should now have a reasonable idea about the strain that resulted in the consultation and the areas to focus on in evaluating the patient. The consultant is now ready to interview the patient. The patient should be provided as much privacy as possible. If the patient is in a ward or a room with other patients, the consultant should draw the curtains around the patient's bed; if the patient is in a private room, the consultant should close the door. If there are visitors with the patient, the consultant should introduce him- or herself by name only and ask who they are, and then ask them to wait outside for a few minutes while the consultant talks with the patient. The consultant should not identify him- or herself as a psychiatrist until the visitors have left. An exception to this is when the patient's cognitive function is known to be impaired, in which case the visitors may remain, with the patient's permission, as they might be able to provide valuable history and additional information.

The consultant should ask the patient whether he or she was told that a psychiatric consultation had been requested. If the patient says no, the consultant should explain that the patient's primary doctor requested the psychiatric consultation for a comprehensive evaluation, which may be for anxiety, depression, mood changes, memory problems, etc. The consultant should reassure the patient that many medical conditions and medications, as well as the stress of being in the hospital, can cause such problems and that they can be managed effectively.

The initial interview should ordinarily take not more than 30 minutes, and should identify the patient's current concerns, the presence of major or minor psychiatric syndrome and its history, past history of psychiatric problems, the family history, the occupational status of the patient, and current mental status. In general, if the patient is confused or delirious, a mental status exam may be performed in lieu of a history, which may have to rely on collateral sources. When a patient is not confused, the cognitive exam may be performed for five minutes or less at the end of the interview, which can be prefaced by first asking, "How is your memory lately?" followed by, "I'd now like to ask you some questions to assess your current memory and concentration."

3.3.5.1 The Mental Status Examination

The mental status consists of the following components: (1) appearance; (2) levels of consciousness and orientation; (3) status of the communicative facilities (speech and movement); (4) content of thought; (5) affect and mood; and (6) cognitive processes (attention, concentration, comprehension, memory, perception, thinking logical thoughts, abstraction, judgment). For patients with cognitive deficits, the Mini-Mental Status Examination (MMSE), in addition to the full mental status examination described here, is useful in quantitatively determining the extent of cognitive deficit, and, when used serially, in documenting changes in cognitive function (see Chapter 8).

3.3.5.1.1 Appearance: Appearance is an excellent indicator of the sum total of a patient's mental status at a given point in time. Body build should be first noted, for example, medium, slender, emaciated, moderately obese, morbidly obese, etc. A sloppy, disheveled appearance often signifies self-neglect or preoccupation and distraction. A flushed appearance and the smell of alcohol on the breath, combined with characteristic drunken behavior, point to the diagnosis of alcoholic intoxication. A pale, emaciated appearance, accompanied by malodorous and sloppy clothing, may indicate the presence of depression or cachexia. Some patients with a lesion in the nondominant hemisphere of the brain may dress only one side of the body, completely oblivious to the presence of the other side. Such patients may pay attention only to one half of the visual field. Notations on appearance should include observations on the general impression made by the patient (e.g., neat or sloppy), including any unusual features (e.g., completely shaved scalp, unusual bodily habitus or dress).

3.3.5.1.2 Levels of Consciousness and Orientation: Awareness of self and environment constitutes consciousness in the mental status examination. Consciousness may be subdivided into the content of consciousness and arousal. The sum total of mental functions, including the ability to remember and to think, comprises the content of the consciousness, while the appearance of wakefulness and response to stimuli form the basis of inference concerning arousal. The content of consciousness is largely a function of the cerebral hemispheres, while the state of arousal is largely a function of the reticular activating system in the brainstem.

3.3.5.1.2.1 Arousal: Levels of consciousness may be classified as follows:

Hyperalert state: Increased state of arousal in which the patient is acutely aware of all sensory input. Anxiety and certain central nervous system stimulants can cause this state.

Normal degree of alertness.

Dullness and sleepiness: May be due to fatigue and insomnia, as well as to sedating medications (as either the primary effect or a side effect). Metabolic derangements due to disease can also result in dullness and sleepiness, such as in uremia and hypercalcemia.

Clouding of consciousness: A state of reduced wakefulness in which periods of excitability and irritability often alternate with periods of drowsiness. Illusions, especially visual, may occur, and the patient is often startled. Mild to moderate toxic states, withdrawal states, and metabolic derangements can be the cause.

Confusional states: In addition to clouding of consciousness, there is consistent misinterpretation of stimuli and shortened attention span. There is disorientation at least to time and often to place. Memory is often poor, and the patient appears perplexed. This is a more severe degree of clouding of consciousness.

Delirium: When used to denote a particular and often fluctuating level of consciousness, delirium may include a florid state of agitation, disorientation, fear, misperception of sensory stimuli, and, often, visual hallucinations. The patients are often loud, talkative, and suspicious, and are sometimes completely out of contact with the environment. The degree of contact may vary. Delirium usually occurs in moderately severe toxic states and metabolic derangements of the central nervous system, including withdrawal from central nervous system depressants such as alcohol and barbiturates.

The term delirium is sometimes used to denote all reversible organic brain syndromes due to metabolic encephalopathy. When used in this sense, delirium is in contrast to dementia, which implies irreversible changes in the brain. Agitation and florid psychotic picture may be lacking in patients with delirium in this broader sense; that is, the patient with reversible confusion and disorientation may be placid and drowsy rather than agitated.

Stupor: In this state, the patient is unresponsive to stimuli unless their application is very strong and repeated. Stupor is usually caused by diffuse cerebral dysfunction.

Coma: complete unresponsiveness to stimuli. Even strong and repeated stimuli cannot arouse the patient. This occurs in severe dysfunction of the brain, such as serious intoxication or severe head trauma.

3.3.5.1.2.2 Content of Consciousness Orientation refers to the person's consciousness of the orienting markers, such as correct awareness of time, place, and person. Impairment of orientation results in confusion. The orientation of a patient is determined by asking questions such as, "What day of the week is it today?" "Where are you right now?" "What is your name?" In case of insufficiency in the cerebral cortical functions for any reason (most often due to metabolic derangement of the brain or neuronal destruction), orientation may be impaired to varying degrees. Impairment of orientation usually proceeds in order from time to place to person. In hospitalized patients, disorientation as to date is not uncommon, perhaps due to the change in daily schedule following hospitalization, distractions by the medical procedures, and other disruptions in the patient's usual routine. In the absence of cerebral insufficiency, however, most patients are oriented to the month and year if not to the exact date. In contrast, orientation as to person, especially to the patient's self, usually is not impaired until the very last stage, although the patient may often forget the names of others, especially those persons encountered recently. Disorientation to the self despite a relatively normal mental status examination in other areas strongly suggests a dissociative syndrome rather than an organic brain syndrome.

3.3.5.2 Status of Communication Facilities (Speech and Movement)

In assessing the communicative facilities of a patient, one should consider the integrity of the apparatuses, the effect of learning and psychological state, and the content of the communication.

3.3.5.2.1 Integrity of Apparatuses: The organs related to speech and movement should be assessed. Weakness of the tongue or facial muscles may produce dysarthria (difficulty in articulating words). Hemiplegia may cause the patient to gesticulate with only one hand. A painful lesion in the mouth may force the patient to be verbally noncommunicative. Deafness may result in nonresponse to a question.

Disorders of language (aphasia) caused by brain lesions may be present. Aphasia should be distinguished from dysarthria; the former is due to problems with language itself at the brain level, while the latter refers to difficulty in articulation. In aphasia, written language as well as verbal speech is affected. Aphasias may be roughly classified into expressive and receptive types. Expressive aphasia is related to lesions of the motor speech (Broca's) area in the dominant frontal lobe of the brain. The patient with expressive aphasia has major difficulties in translating thoughts to symbols; thus, what the patient wishes to express may come out in a distorted form or not at all. Patients are usually aware of this distortion or difficulty in their speech and thus are usually reluctant to speak (or write). Receptive or sensory aphasia is due to lesions of the sensory speech (Wernicke's) area of the dominant temporal lobe. In this condition, patients have difficulties in comprehending language, including their own speech. Thus, patients' speech may be garbled, but they may not be aware of it. Unlike patients with expressive aphasia, those with the receptive form are usually fluent, although often incomprehensible to others. There are varying combinations and subtypes of aphasias.

3.3.5.2.2 Effect of Learning and Psychological State: Given intact apparatuses for communication, the form of communication often depends on the patient's psychological state and the effect of learning. The effect of learning determines the language in which the patients will express their feelings and thoughts as well as the fluency and facility of the language. For example, middle-class patients are more likely to use grammatically correct syntax. Some patients may use dialects or culturally specific expressions. The current psychological state also determines speech and nonverbal communication. A euphoric patient is more likely to be effusive, verbose, and flamboyant; a depressed patient may be uncommunicative and withdrawn.

3.3.5.2.3 Content of Communication: What the patient is communicating forms the content of communication. The content of communication often reveals the patient's psychological state, for example, themes of hopelessness and death in depressed states, and bizarre contents in psychotic states. Extreme suspiciousness and ideas of persecution may indicate paranoid psychosis.

3.3.5.3 Affect and Mood

In current usage, mood denotes the subjective feeling/emotion of the patient (euthymic, sad, happy, depressed, euphoric, etc.), while affect refers to the way the emotion is expressed (normal range, flat, obtunded, labile, appropriate, inappropriate, etc.). In another, common usage, affect refers to feeling and is synonymous with emotion, while mood refers to prevailing and relatively enduring emotional tone. Mood can be documented by observation and direct questioning. By observation, one can see whether the patient's affect is appropriate or inappropriate relative to the topic of conversation (does the patient smile while talking of sad events?) and whether it is stable or labile. Labile affect, as manifested, for example, by laughing one minute and crying the next, may be indicative of organic brain dysfunction, in which case there will be additional signs of cognitive difficulties. Flat affect means the absence of any display of affect and is often associated with extreme use of isolation as a defense mechanism or with schizophrenia. Physiological signs such as sweating, rapid heart rate, and facial expressions also reveal affective states. Family, friends, and relatives of the patient may also provide useful information concerning the patient's mood.

3.3.5.4 Cognitive Processes

These are the processes that determine the content of consciousness. The processes include attention, perception, memory, concentration, comprehension, abstraction, logical thinking, and judgment. Diminution in the function of any of these areas may indicate the presence of pathology in the cerebral cortex or limbic system. It should be noted, however, that what is important is a decrease in function from the premorbid state and not necessarily the absolute level of functioning, since the absolute levels of abstract thinking, comprehension, and other processes may be determined by background and by long-term variables such as constitutional endowment, educational level, and habitual functional level, as well as by illness. For example, cerebral pathology is more probably present in a college professor who cannot remember the names of the past five U.S. presidents than in a blue-collar worker with a tenth-grade education who evinces the same inability.

The cognitive processes can be tested both indirectly and directly. Indirectly, inferences can be made concerning patients' memory, judgment, concentration, comprehension, and other abilities by asking them to describe their present illness and their personal history. Do they remember the dates (or years) of graduation from school, marriage, and other significant events? Do they comprehend the nature of their illness and the proposed procedures? Do they remember what has been said to them by their physicians? Do they seem to be aware of the possible risks and complications?

When there is any question concerning the patient's ability to concentrate, comprehend, or think in a logical fashion, a direct and formal testing of the cognitive functions may be necessary.

3.3.5.4.1 Direct Tests of Cognitive Processes: In introducing direct tests of cognitive processes, it may be helpful to explain that the tests evaluate memory, concentration, and so forth, and so are useful in evaluating possible mental effects of medications, procedures, and the illness itself. For example, sedating medications may need to be reduced if the patient is found to be too drowsy or if concentration is diminished. This type of reassurance may put patients at ease about possible errors they may make and gives the testing a medical context.

3.3.5.4.1.1 Orientation The significance of orientation was discussed above. When doing direct cognitive testing, it is useful to ask questions concerning orientation first. The questions may include "What day is today?" "What is the date (or day of the week)?" If the patient does not know, ask, "What month is it now?" "What year?" Mild disorientation as to time (e.g., not knowing the date) is common even among normal persons, but severe disorientation (e.g., not knowing the month and year) is indicative of a cognitive disorder.

"Where are you right now? What is the name of this place?" These questions test orientation as to place. If the patient does not know, ask, "Are you in a hospital, a hotel, or a supermarket?" Patients may know that they are in the hospital (or a doctor's office) but may not know the name of the hospital or clinic, which indicates a milder degree of dysfunction than not knowing the nature of the place or confusing it with somewhere else, such as a hotel room.

The next question (orientation as to self) is "What is your name?" As discussed previously, dysfunction in orientation proceeds in an orderly manner from time to place to person. In fact, except in cases of very severe brain disease, orientation as to self is usually well preserved. Of course, a delusional patient may have a distorted orientation as to self, stating, for example, "I am Napoleon Bonaparte."

3.3.5.4.1.2 Memory, Attention, Concentration, and Comprehension Ask, "Who is the President of the United States now?" If the patient answers correctly, continue by saying, "Yes, and the previous President?" until four or five names have been given correctly. This tests the patient's recent memory and information. Most patients with a high-school education can remember four or five recent presidents.

Asking the patient to do simple arithmetic calculations can test the patient's ability to attend to and comprehend the physician's instructions and to concentrate and utilize immediate memory. "How much is 15 plus 17?" "25 minus 7?" If the patient has difficulty, an easier calculation involving single digits should be tried. Unlike additions and subtractions, simple multiplications, such as 4 times 6, are easier tasks, since they involve primarily long-term memory (which is resistant to decay) and comprehension of the instructions. Thus, if the patient can do 4 times 6 but not 15 plus 17, then one might wonder whether the patient has difficulties with concentration and immediate or recent memory but not with remote memory and comprehension (indicating possible brain dysfunction). On the other hand, if the patient has difficulties with both, low educational level or mental retardation might be suspected.

If there is reason to suspect difficulties on the basis of simple calculations, serial 7's and digit span testing might be done. For serial 7's, ask the patient to subtract 7 from 100 and to keep subtracting 7 from the results. This tests sustained attention and concentration as well as short-term memory. If serial 7's are too difficult for the patient, serial 5's or 2's may be tried. Digit span is tested by asking the patient to repeat a number of random digits, not including zero, such as 5-7-2-8-6. Digit span backward is tested by asking the patient to repeat the numbers in reverse order: "For example, if I say 1-2, you say 2-1." This tests primarily short-term memory and concentration. Most patients without brain dysfunction can do at least six digits forward and four digits backward. Failure to repeat six digits forward strongly suggests cognitive impairment. In contrast, the ability to repeat five numbers backward suggests that a brain dysfunction is very unlikely.

Memory, especially recent memory, is very sensitive to dysfunction of the brain. The hippocampus is involved in the coding of recent memory into the long-term memory mechanisms. Any metabolic derangement of the hippocampus and the cerebral hemispheres can result in problems with memory. When memory dysfunction is suspected, the registration, retention, and recall of memory can be tested by the following steps: First, ask the patient if he/she remembers your name. If the patient does not remember it, repeat your name and ask the patient to repeat it (immediate memory: registration and immediate recall). Then, tell the patient that you will name three objects that you are asking him/her to remember, as you will ask again in a few minutes. The objects may be items such as "apple, penny, and table." Ask the patient to repeat the names of the three objects immediately. In about five minutes or so, ask the patient if he/she remembers your name and the names of the three objects (recent memory: retention and recall). The patient may be able to remember only one or two objects (diminished recent memory). If the patient cannot recall any of the objects, say, "Please say yes if any of the objects I name now is one of the objects I named before." If the patient can now identify the objects, it may indicate the presence of retention but difficulty with recall.

3.3.5.4.1.3 Abstraction Test the ability of the patient to categorize objects on the basis of similarities. For example, "What is the similarity between a cat and a dog?" The patient may reply, "They are both animals" (a good abstraction) or "They both have legs" (a concrete response). (In case of the latter, you might then ask, "How about a dog, a cat, and a snake?" At this point, the patient may be able to abstract and say, "They are all animals.") An idiosyncratic or bizarre response, such as, "They are both my enemies," may indicate an unusual way of thinking, as in psychosis.

Interpretation of proverbs, such as, "Don't' judge a book by its cover" and "Don't cry over spilt milk," is most subject to influences of educational level, cultural background, and language. For example, patients from non-English-speaking cultures may have great difficulty in abstracting English-language proverbs. A concrete response in tests for abstraction may indicate possible brain dysfunction, low educational level, low intelligence, or formal thought disorder, as in schizophrenia. An idiosyncratic or bizarre response may indicate an unusual way of thinking, as in psychosis. For example, "What does the proverb `People who live in glass houses shouldn't throw stones' mean?" "It means that even if you have enough money to buy a glass house, you should not throw away money. Stones are gems, you know, which cost a lot of money."

3.3.5.4.1.4 Logical Thinking and Judgment Patients with brain dysfunction may show varying degrees of difficulty with judgment. Judgment means the ability to act appropriately in social and emergency situations. Many questions concerning judgment also involve the ability to think logically. For example, "If you were in a crowded theater and happened to discover fire and smoke coming from the ceiling, what should you do?" A good answer would be "I would tell the usher or manager." If the patient replies, "I would yell `Fire,' " the physician might ask, "If you yelled `Fire,' what would happen?" The patient with intact logical thinking may then say, "I guess that would cause panic ... perhaps I should not yell `Fire.' " (Another judgment question is, "What should you do if you found an envelope with an address and a stamp on it in the street?") Patients with personality disorders without organic brain dysfunction may give idiosyncratic or inappropriate responses to judgment questions. For example, an impulsive patient may say, "I would try to put out the fire by throwing my can of soda on it."

3.3.5.5 Perception

The patient's perception can be tested by first observing whether the patient seems to be aware of the tester's presence and whether the patient seems to be responding to visual or auditory hallucinations (e.g., carrying on a conversation). Then, the patient can be asked questions such as, "Have you ever had any experiences of hearing things or seeing things that others couldn't see or hear?" "Any experiences of things changing shape or becoming distorted?"

3.3.5.6 Delusions and Paranoid Thinking

A delusion is an idea firmly held by a patient that is not corroborated by reality. Delusions may be grandiose ("I am God"), persecutory ("Everybody is out to get me"), or depressive ("Worms are eating my brain out"). Some delusions involve diseases, such as, "I know I have cancer, no matter what the tests show." The term paranoid is often used to describe patients who have persecutory ideas or delusions.

The presence of delusions is usually manifested by the content of the patient's communications. Delusion formation is a process by which perceptions are put into some kind of perspective. Thus, strange bodily sensations, due to whatever cause, may be attributed to "poisoning" and continuing presence of anxiety to "people spying on me." Obviously, when cognitive processes are not functioning optimally, and when the anxiety level is high (such as in a hospitalized patient with preexisting cognitive difficulties due to poor blood supply to the brain), the risk of delusion formation is greater; it is easier to misperceive stimuli or attribute confusing stimuli to a cause unrelated to reality (e.g., "The doctors are trying to kill me so that they can give my kidneys to someone else").

In addition to indicating the possible presence of cognitive difficulties, delusions give clues concerning the emotional state of the patient. For example, persecutory delusions are associated with anxiety, grandiose delusions with euphoria, and depressive delusions with a depressive syndrome.

3.3.6 Obtain Collateral Information

At the end of the interview, the consultant should obtain permission from the patient to speak to his or her spouse or significant other, family members, and friends to obtain collateral information. If the patient is severely cognitively impaired, or the patient refuses to give permission, the consultant may still speak with the others as long as they are aware that the patient is in the health care facility and as long as the consultant only obtains information and does not divulge information about the patient.

3.3.7 Diagnose the Consultation: The Syndrome, the Patient, the Environment

After reviewing the reason for the consultation, patient's history, the family history, information received from collaterals, the laboratory findings, and the vital signs and physical examination findings, the consultant is in a position to make a comprehensive diagnosis. Such a diagnosis may include primarily a systems strain, for example, a personality or opinion conflict between the health care professional(s) and the patient (see Chapter 28). When the patient shows evidence of a psychiatric condition, the consultant develops a differential diagnosis leading to a working diagnosis of the psychiatric syndrome, its interaction with the medical condition, and an understanding of the patient as a person dealing with the medical and psychiatric condition. Such an understanding takes into account the patient's developmental history and childhood, recent and current stresses, as well as the patient's coping ability and psychosocial assets. Differential diagnosis of the psychiatric syndrome should be from general to specific, for example, psychotic syndrome that may be secondary to drug use and/or to delirium caused by electrolyte imbalance and/or increased serum ammonia. Very often, the psychiatric syndrome presents multiple possible contributing etiologies; for example, major depression may be a recurrence of existing unipolar depression, plus the effects of chronic alcohol abuse, plus secondary to hepatic failure, plus cocaine withdrawal. (See Chapter 6 for further discussion of psychiatric diagnosis).

3.3.8 Provide Diagnosis and Recommendations

The consultant should report the diagnosis and treatment recommendations to the referring physician, either directly or on the phone, so that the referring physician may be able to ask questions and discuss the findings with the consultant. The consultant should communicate to the consultee the findings and diagnosis clearly and concisely, without using unnecessary psychiatric jargon, and discuss alternative treatments and recommendations. The recommendations should be presented very concretely and should specify who is to do what. For example, "I recommend prescribing olanzapine 10 mg po hs on a regular basis, plus lorazepam 1 to 2 mg IV q 4 firs prn for agitation. Please tell the nurses to orient the patient each time they do any procedure such as taking the vital signs; they should say, `I am Nurse so and so and I am going to take your blood pressure."'

This conversation with the referring physician should be followed by a written consultation report. The report should be concise and legible. It should contain, as a minimum, the reason for referral, a brief history, the mental status examination, the relevant lab findings, the working diagnosis (usually multiaxial diagnosis), and the specific recommendations.

3.3.9 Consultation Interventions

In the course of a psychiatric consultation, the consultant provides intervention through the empathic interview process, and through the supportive psychotherapeutic elements inherent in a psychiatric interview. In addition, the consultant may provide immediate relief of agitation through listening and reassurance, and when indicated, with stat medications. There may be a need for an involuntary hold if the patient is considered to be dangerous to self or others and is in need of psychiatric hospitalization.

The consultant may find it advisable, at times, to meet with the nurses, to meet with the patient's family, or to meet with the patient, the referring physician, and others to facilitate communication or plan a course of action.

The consultant may also perform specialized procedures such as the lorazepam interview or hypnosis (see Chapter 29).

3.3.10 Follow-Up

At least one follow-up visit is recommended for all initial consultations whenever feasible. A follow-up visit is valuable in determining any changes either as a result of the treatment recommendation or in the disease process. In delirious patients, the fluctuation in mental status during follow-up visits may be diagnostic. When a patient no longer requires follow-up but is still in the health care system, the consultant should sign off and communicate it to the referring physician.

3.4 Computerized Psychiatric Consultation Database

I developed a computerized psychiatric consultation database with forms, reports, and queries, which is a Microsoft Access database application. It is available free of charge as a download from Springer. This database is used at the Community Regional Medical Center in Fresno, California. To download, please visit the Handbook website: www.springer.com/978-0-387-69253-1



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