Term
| AMS in delirium vs dementia vs psychosis |
|
Definition
delerium- rapid onset, fluctuates, abnormal vitals, altered lvl of consciousness, visual hallucinations, PE abnormal, poor prognisis if not tx, organic cause
dementia- slow onset, progressive course, normal vitals, normal lvl of consciousness, rare hallucinations, normal PE, prognosis progressive, organic cause
psychosis- variable onset, variable course, usually normal vitals, variable level of consciousness, auditory hallucinations, normal PE, variable prognisis, functional underlying cause |
|
|
Term
| differential diagnosis for psych |
|
Definition
• M: Metabolic—B12 or thiamine deficiency, serotonin syndrome
• O: Hypoxemia (pulmonary, cardiac, anemia); high CO2
• V: Vascular causes—hypertensive emergency, ischemic/hemorrhagic CVA, vasculitis, MI
• E: Electrolytes and endocrine
• S: Seizures/status epilepticus, post-ictal
• T: Tumor, trauma, temperature, toxins (lead, mercury, CO, toxidromes)
• U:Uremia.Renalorhepaticdysfunctionwith hepatic encephalopathy
• P:Psychiatric,porphyria
• I:Infection(inflammatory—seevasculitisabove)
• D:Drugs,includingwithdrawal(anticholinergics, TCA’s, SSRI’s, BZD’s, barbiturates, alcohol) |
|
|
Term
| common reasons for altered mental state |
|
Definition
aeiou
A
Alcohol
E
Epilepsy, Electrolytes, and Encephalopathy
I
Insulin
O
Opiates and Oxygen
U
Uremia
T
Trauma and Temperature
I
Infection
P
Poisons and Psychogenic
S
Shock, Stroke, Subarachnoid Hemorrhage and Space- Occupying Lesion |
|
|
Term
|
Definition
• Mood disorders (abnormally high or low mood)
• Affect that is depressed or flat (or too high and chipper)
• Loss of interest in usual activities, reduced (or increased) activity level, changes in appetite or sleep patterns, crying, speech that is slowed or speeded up, feeling worthless, and death wishes or thoughts of suicide |
|
|
Term
|
Definition
• Nervousness,excessive worry, panic, unreasonable fears, a history of severe emotional or physical trauma
• Physicalcomplaintssuchas palpitations, irregular heartbeat, sweating, trembling, trouble breathing, and dizziness |
|
|
Term
|
Definition
| • Delusions,hallucinations in any of the senses, bizarre behavior, speech that is incoherent or hard to follow, flat or inappropriate affect, fantasies or illogical ideas, social withdrawal, and impaired insight or judgment |
|
|
Term
| Difficulty Thinking—Cognitive Disorders |
|
Definition
| • Includes defects of memory, delusions, hallucinations, fluctuating affect, bizarre or unpredictable behavior, and poor judgment |
|
|
Term
| Social or Personality Problems |
|
Definition
• May be suggested by repeated marital conflicts, legal difficulties, peculiar or bizarre behavior, a presentation that is overly dramatic or ingratiating
(or grumpy), or by job problems: being fired, demoted, repeatedly tardy
• Obsessions or compulsions |
|
|
Term
|
Definition
• Can be signaled by losing or gaining appetite or weight, convulsions, headache, weakness, neurological complaints, and pain that can occur in one or more of many locations throughout
the body
• Medical or mental history that is vague or complicated may warrant further investigation
• Ask about history of sexual abuse or verbal or mental abuse
• Repeated treatment failures may have an underlying mental cause |
|
|
Term
|
Definition
• ETOH daily amount
• Financial or legal problems
• Health consequences of use (cirrhosis, blackouts, abdominal pain, vomiting)
• Social consequences such as fights, marital problems, and loss
of friends |
|
|
Term
| Starting Out psych interview |
|
Definition
• Start with brief questions
• Psychiatric patients don’t prefer small talk
• Ask open-ended questions
• Refrain from yes or no questions
• Refrain from multiple choice answers
• Avoid leading questions
• Avoid double questions, laundry lists
• Encourage precision, dates, times, numbers
• Don’t phrase questions in the negative |
|
|
Term
| Setting Up psych interview |
|
Definition
• Assess the situation—do you need back-up?
• Remove dangerous objects or anything that can be used as a weapon.
• Objects of metal, plastic, or wood—or within reach or tucked inside of clothing—
should be assessed.
• Be careful when checking pockets—syringes.
• When moving objects, try to make it look like normal activity rather than ready for battle.
• If you can reasonably rule out the patient is without a weapon, then start the de-escalation process.
• Bringing the patient in—you may need help from security, police, EMS.
• You may need a wheelchair, stretcher gurney,
straps, or vest.
• You may need a sedative medication. |
|
|
Term
|
Definition
• Whatyousaymatters,
and how you say it matters.
• Positivestatements:
– “This is fantastic”
– Rather than, “... now that you’ve finished with
your episode” |
|
|
Term
|
Definition
• Watch your patient’s demeanor
• If patient is depressed, move closer and show support
• If hostile, give the patient space
• Maintain eye contact
• Nod
• Speak with compassion
• Avoid jargon
• “I’ve never experienced [that situation], so I can only imagine how horrible you feel.”
• “Icanseethatitupsetyouterribly.” • “Youmusthavefeltmiserable.”
• Beobjective,evenifitangersyou. • Besincere,patientscantell.
• Offerchoicesandbeoptimistic. • Donothumiliateormakejokes. |
|
|
Term
|
Definition
• Ifethnicityorpatient’s dialect makes it hard for you to understand, it’s hard for them to understand you too
• Donotjudge
• Learn
• Askquestions
• Higherpowerversusreligion |
|
|
Term
|
Definition
• Don’t overreach for information
• Don’t reveal too much information about yourself
• Okay to find a common ground, might encourage rapport,
but don’t do more than
once with a patient
• Avoid politics
• Avoid religion
• Avoid giving your age: “Why do you ask?” |
|
|
Term
|
Definition
• Doesn’t mean angry
• Means something needs clarification
– Acontradiction
– Historical inconsistency
• “Help me understand”
• “Earlier you told me ___ but
I thought you mentioned this”
• Use sparingly—you don’t want to argue with a patient
• Agree to disagree |
|
|
Term
|
Definition
• Interviewersoftenneglect to ask about feelings
• Use“howdidthatmake you feel” rather than “what did you think?”
• “Whatwasyour state of mind?”
• “Howare/were your spirits?” |
|
|
Term
|
Definition
• Emotions sometimes interfere with communication.
• Some people do not understand their own emotions.
• Some people grew up in households in which anger and yelling were primary forms of communication.
• Some people will be in tears the whole time.
• Label the emotion for the patient: “You feel angry and frustrated”—“Sad and lonely.”
• Speakquietly—anangrypatientwilllowertheir voice if straining to hear you.
• Sometimesyouneedtoswitchtoclose-ended questions, interrupting if the patient is getting angry or wound up on a particular answer. This helps with keeping the patient sticking to the subject. |
|
|
Term
|
Definition
• Too quick • Too slow
• Flat affect • Too bubbly |
|
|
Term
|
Definition
-everything!
• If you didn’t write it down, it
didn’t happen!!! |
|
|
Term
|
Definition
• Remember, psych patients may not want to be a patient
• Many times patients are scared, confused, angry, and even combative
• Some patients don’t know why they are there
• Avoid overreacting
• Stay calm
• Don’t make judgments
• Ignore challenging questions
• Gather a team |
|
|
Term
|
Definition
-ensure your safety!
-Provide an unobstructed
exit from your interview room
• Place yourself closer to the door than the patient
• Know your exits
• Check the room for safety panic alarm button
• Ensure that someone knows where you are
• Make sure someone is within earshot of a call for help
-use a chaperone
-Be wary of any patient who has a history of violence
• Be wary of any patient who takes antipsychotic medication and hasn’t taken it lately!
• Watch out for the patient with a previous history of violence
• Watch out for indicators of potential violence in the patient’s voice (rising tempo or pitch), words (threats/insults), body language (agitation/clenched fists)
• If you sense danger, announce that you are leaving the room as to not startle the patient |
|
|
Term
| Behavioral Activity Rating Scale—BARS |
|
Definition
1 = Difficult or unable to rouse
2 = Asleep but responds normally to verbal or physical contact
3 = Drowsy, appears sedated
4 = Quiet and awake (normal level of activity)
5 = Signs of overt (physical or verbal) activity, calms down with instructions
6 = Extremely or continuously active, not requiring restraint
7 = Violent, requires restraint |
|
|
Term
| De-escalation: Taking Charge |
|
Definition
• Determine the lead negotiator.
• Patients may focus on a person.
• They may focus negatively.
• They may focus on a person who reminds them of someone.
• If a patient focuses in on
someone negatively, that person needs to step away.
• If you recognize that you are getting angry or upset, you must pull yourself away.
• Step in front of someone if need be. |
|
|
Term
| De-escalation: Establish Trust |
|
Definition
• Create a break in the tension
• Introduce yourself
• Call the person by their name
• Standard greeting |
|
|
Term
|
Definition
• Respect the person’s space.
• Distance is important.
• If you are too close, you are perceived as a threat.
• If you are too far away, this allows the patient to put on a show or shows that you are scared.
• Try to secure exits or escape routes.
• Do not corner the patient |
|
|
Term
|
Definition
• Findouttherootof the problem.
• Askthemwhatis bothering them.
• Useempathy:
– “I can see why you feel that way.”
• Iftheywon’tshare,trytostepbackandreword. – “I can see you are upset, maybe I can help you.” |
|
|
Term
| De-escalation: Solving the Problem |
|
Definition
• Trytosolvetheproblem if you can.
• Neverpromiseanything.
• Trytobepositive.
• Trytoofferhelp,finding a resolution, checking/consulting with someone else. |
|
|
Term
|
Definition
If peaceful communication fails:
• Placing hands on the patient may be necessary
• Do not attempt by yourself
• Train with staff to hold together
• Must attempt to restrain
simultaneously or risk of injury increases
• Gurneys, handcuffs, leather, nylon restraints or cushion pads may be necessary
• PRN medication orders may be necessary—sedative |
|
|
Term
|
Definition
• May be fearful
• Reassuring an angry person in calm, repetitive statements may just buy your way out of a fight |
|
|
Term
| Knowing When to Intervene |
|
Definition
• Choose your battles
• Let patients vent
• Maybe they need to scream in the corner or break everything in the room
• Don’t risk your life |
|
|
Term
|
Definition
• Youmustfollowupwith the patient.
• Letthepersonknow what was done to solve the problem.
• Letthepatientknowtheplanmovingforward.
• Offerassistanceatanytime.
• Provideencouragement. |
|
|
Term
| Reluctant or Quiet Patient |
|
Definition
• Ask open-ended questions
• Refrain from yes or no
• Try to shift gears and talk about non-psychiatric illness to build rapport
• Ask them their reason for being there if in PC setting
• Explain pros and cons
• Meet them where they are at: “How may I help you?”
• Find something they like to talk about |
|
|
Term
|
Definition
• Use close-ended questions, use sparingly in between open-ended questions
• Yes or no
• Don’t ask the patient to elaborate
• Use multiple choice questions sparingly
• Gentle interruption and redirection – Empathetically
– Delaying
– Educating |
|
|
Term
|
Definition
• Patients feel everything is urgent
• You are their Amazon Prime/service industry
• Need special attention, they require a lot of reassurance
• May be the “good, compliant” patients who know what they want
• You will be made to feel like a hero and then exhausted when you can’t do right by them
• Give them written instructions |
|
|
Term
|
Definition
• Verbalizeboundariesonphonecallsandrefills
• Don’tover-promise
• Spelloutpatientresponsibility
• Emphasizetheirroleintheirillness,otherwise you are blamed for their relapse |
|
|
Term
|
Definition
• Appears smug, vain, grandiose
• Entitled
• “I only see the best of the best”
• May try to control you with demands/threats of lawsuits
• Easy to become angry or hostile
• Avoid arguing
• Acknowledge their POV
• Focus on how you can help |
|
|
Term
|
Definition
• They feel at a loss when not in control.
• They do not want to be being seen by you.
• They may come in with lists telling you what needs
to be done.
• You should help relieve their anxiety.
• Provide ample explanations as to why/what you are doing and what’s next.
• Explaineachsign,symptom,labtest,PE, diagnosis, treatment, and prescription in detail. Have them write it down, and you write it down.
• Summarize.
• Askthemifthereisanythingelseyoucan explain.
• Outlineyourplanforthem,andifyoudon’t know the answer, outline your plan to figure it out. |
|
|
Term
| Dramatic/Manipulative/Histrionic |
|
Definition
• May need to be center of attention
• Views illness possibly as a weakness
• Identify what the patient gains from this behavior-attention
• Be calm, gentle, and firm with plan
• Summarize patient’s story frequently so they know you are paying attention
• Avoid being judgmental
• Give positive feedback for the patient’s strengths |
|
|
Term
|
Definition
• Rejects help
• Never ending bad luck
• May disregard own needs to help others
• Don’t ignore patients’ pessimism, help validate their feelings, and work with them to see a balanced view
• Don’t be overly cheerful
• Don’t patronize
• Don’t focus solely on patients’ strengths
• They need to feel heard |
|
|
Term
|
Definition
• Suspicious of you, your staff, the medical system!
• Suspicion increases in times of distress.
• Do not argue with this patient or contradict; focus on clarifying what you can do to help.
– Clear explanations
– Explain your role and limitations
– Remain calm and friendly
– “It must be frustrating not knowing what is going on”
– Clarify that you understand your patient’s beliefs while indicating you do not necessarily agree with them |
|
|
Term
|
Definition
• Expression of psychological distress or emotional discomfort via physical symptoms
• Symptoms not completely accounted for by organic evidence
• Many work-ups, many providers, no effective outcome
• Sick leave, disability, consume a lot of clinic time, difficult to interview
• Must review full medical history and full work-up to evaluate
• The medical system, in fact, may be creating a positive feedback loop to promote this thought process
and behavior. Vague, inconsistent, bizarre
symptom descriptions:
– Symptoms persist despite seemingly appropriate treatment
– Onset is in context of psychologically meaningful situation
– Patient denies emotional distress or psychological reasons
– Poly-doctoring/surgery common
– Evidence of an associated psychiatric disorder common
– Features of hysterical personality style
– Individualized meaning attributed to symptoms by the patient
– Difficulty describing emotions or internal emotional experiences in words
• Buildtrust,include“healthytalk”
• Regularvisitsinsteadofcrisisvisits
• CreatecleartimelineinHPIandPMH
• Donotputoffscreeningstandardexamsforfear of encouraging patient
• Prioritizepatient’sconcerns
• Educateonthemind-bodyconnection |
|
|
Term
|
Definition
• Illness can create feelings of helplessness, fear of pain, death, disability, loss of love, uncertainty
• Illness can provoke unhealthy coping mechanisms
• Patient might appear facial flushing, sweating, rapid speech, fidgeting, trembling
• Acknowledge the feelings and work together
• Remain calm and unhurried
• Sympathize but not extremely so, because then
patient feeds into the fear of something else being wrong
• Be specific in follow-up instructions
• Normalize the anxiety
• Explain as you proceed through the HPI of why asking |
|
|
Term
|
Definition
• Usually taken out on provider
• But usually stems from elsewhere—remember that!
• Anger may actually be masking depression
• Acknowledge anger, help patient cope
• Validate that the patient is struggling with
these negative feelings (knowing that you don’t have to agree with the logic of them)
• Explore patient’s feelings of helplessness, fear, disappointment, jealousy
• Do not get defensive
• Help patients recognize healthy methods to cope |
|
|
Term
|
Definition
• Specific questions
• Be patient
• Patient may need extra time
• Patient may be familiar with these questions and not be truthful out of fear or embarrassment
– Do you get pretty discouraged?
– What do you see for yourself in the future?
– Have you had thoughts either recently or even in the past about harming or killing yourself?
– Have you ever gotten to the point of coming up with a plan of how you might hurt or kill yourself?
– Are you currently having thoughts of hurting or killing yourself? |
|
|
Term
|
Definition
• Can lead to serious delays in care
• May be an acute coping mechanism
• Approach with care
• Gently explore the patient’s
knowledge and understanding of the situation
• Offer clear explanations about probable outcomes |
|
|
Term
|
Definition
• Make sure you take care of yourself before others
• Recognize your own counter-transference
• Take time and space if you need it to reflect after the patient leaves or at the end of the day
• Share your feelings with others, vent
• Don’t internalize
• Breathe in the emotion you want to feel, and then release the negative emotion with your out breath |
|
|
Term
| Source/Reliability for psych |
|
Definition
• Psych patients are not always reliable
• Potential sources: family members, police, EMS, community mental health resources, old records, consultation, child’s teachers, religious or spiritual leaders, PCP, alternative complementary providers
• Legal status (guardian of the courts, parole) |
|
|
Term
|
Definition
• What brings you in today? – Find out the “chief complaint”
• Psych patients may not think they have a problem.
• In your first line of your HPI, include pertinent PMH, PSH, and psych history, even FH if it is related to the psych complaint. |
|
|
Term
|
Definition
• How is your sleep?
– Insomnia/sleep too much? (depression)
– Wake at night (anxiety, PTSD, heavy drinkers)
• Appetite and weight? (depression)
• Energy level?
• Daily mood?
• Sexual interest and performance?
• Stressors
• Consequences of illness—antisocial, substance use disorders?
• Are the symptoms constant?
• Auditory hallucinations
(noises, mumbled speech, isolated words, complete sentences)?
• Location (inside the patient’s head, in the air, outside the room)?
• Intensity (distant whispers to loud screams)? |
|
|
Term
|
Definition
• Onset—When did it first start/first episode?
• Pain—point with one finger (somatization)
• Provocative/palliative—Anything make it worse or better?
(family, meds, drugs, breathing, rest)
• Quality—What are the episodes like? (mania, depression)
• Radiate—Does it radiate or travel anywhere? Affecting different areas of their life?
• Severity—pain/intensity scale 0–10
• Timing—acute, gradual, chronic, comes and goes (bipolar) |
|
|
Term
|
Definition
| • General, skin, head, eyes, ENT, cardiovascular, respiratory, GI, GU, musculoskeletal, neuro, endocrine, heme/lymph, psych (if not already covered in HPI, past psych history, etc.) |
|
|
Term
|
Definition
• Depression
• Anxiety
• Suicidalideations
• Haveyoueverseen
a mental health provider? |
|
|
Term
|
Definition
• General medical problems
• Depression may be caused by bone cancer, DM, Lyme disease, broken leg
• Psychosis may be as a result of an endocrine disorder
• Head trauma/LOC
• Seizures
• Parkinson’s
• MS
• Autism/Asperger’s syndrome
• Alzheimer’s
• HIV/AIDS
• Thyroid abnormalities
• Cancer
• Hepatitis
• Chronic illness or disabilities
• Toxins/heavy metal exposure
• Delirium
• Dementia
• ADHD
• PTSD |
|
|
Term
|
Definition
• Past hospitalizations—times, amount each time, diagnosis, treatment, continued, completed
• Prior diagnoses (clarify if actually given by health professional)
– SA/SI/HA/HI:priorthoughts/ideation/ plan/method of attempt/severity of attempt
– Inpatienthospitalizations:indication,location,lengthofstay
– Residentialtreatment:indication,where,duration,whyleft
• Outpatient treatment:
– ProvidedbyPCP,psychiatrist,psychologist,SW – Psychotherapy:type,lengthoftime,effectiveness
• Past psych medications: – Drug name
– Indication
– Duration of trial
– Highest dose reached – Effectiveness
– Side effects
– Adherence to regimen
• Other treatment:
– ECT—electroconvulsive therapy
– Vagus nerve stimulation—depression – Transcendental meditation |
|
|
Term
|
Definition
• Craniotomy
• Shunts
• Surgery for cancers
• Gender reassignment
• Surgery to remove bezoar—PICA
• Any surgery can affect the well-being of the patient |
|
|
Term
|
Definition
• Compliance with psych meds!!!
• Side effects of medications can also produce a variety of mood, anxiety, and even psychotic disorders
• Anticonvulsants
• Benzos
• Opiates
• Benadryl
• Dramamine
• Digoxin
• Chantix
• Lithium
• Methadone
• Herbs-Kava, mushrooms |
|
|
Term
|
Definition
• Lithium (Lithobid, Eskalith)
• Lamotrigine (Lamictal)
• Valproic acid/Divalproex (Depakene/Depakote)
• Carbamazepine (Tegretol)
• Oxcarbazepine (Trileptal)
• Antipsychotics (particularly for managing acute severe manic symptoms) |
|
|
Term
|
Definition
• SSRI:
– Fluoxetine(Prozac)
– Citalopram(Celexa)
– Escitalopram(Lexapro) – Sertraline(Zoloft)
– Paroxetine(Paxil)
– Fluvoxamine(Luvox)
• SNRI:
– Duloxetine(Cymbalta) – Venlafaxine(Effexor)
– Desvenlafaxine(Pristiq)
• Other:
– Mirtazapine(Remeron) – Bupropion(Wellbutrin) – Buspirone(Buspar)
• TCA:
– Amitriptyline(Elavil)
– Nortriptyline(Pamelor) – Manyothers
• MAOI:
– Phenalzine(Nardil) – Manyothers |
|
|
Term
|
Definition
• 1st Line: • – SSRI/SNRI
• Benzodiazepine:
– Lorazepam(Ativan)
– Clonazepam(Klonopin)
– Diazepam(Valium)
– Chlordiazepoxide(Librium)
– Alprazolam (Xanax) •
– Temazepam (Restoril)—hypnotic
• Non-benzodiazepine:
– Buspirone(Buspar)
– Hydroxyzine(Vistaril)
– Diphenhydramine(Benadryl) |
|
|
Term
|
Definition
-Atypicals
– Clozapine(Clozaril)
– Risperidone(Risperdal) – Olanzapine(Zyprexa)
– Quetiapine(Seroquel) – Ziprasidone(Geodon) – Aripiprazole(Abilify)
Typicals
– Haloperidol(Haldol)
– Perphenazine(Trilafon)
– Fluphenazine(Prolixin)
– Chlorpromazine(Thorazine) – Manyothers |
|
|
Term
|
Definition
• React poorly to a medication
• Allergy medicines—over excitement
• OTC cough medicines in the past
• Bath salts, jewelry cleanser, herbal incense
• Pain pills
• Mixing St. John’s Wort and Dextromethorphan—serotonin syndrome
• Unisom mixed with acetaminophen or codeine—high
• Remember, meds may be sold OTC in other countries and mixed |
|
|
Term
|
Definition
• Psychiatric illnesses are usually familial and frequently hereditary.
• “I’d like to know whether any of your blood
relatives ever had a nervous or mental disorder.
By ‘blood relatives,’ I mean your parents,
brothers and sisters, children, grandparents,
uncles, aunts, cousins, nieces, and nephews.
Have any of these people ever had nervousness,
nervous breakdown, psychosis or schizophrenia,
depression, problems from drug or alcohol dependence, suicide or suicide attempts, delinquency, hypochondriasis (believed they had a disease or illness and do not), mental hospitalization, or arrests or incarcerations? Any relatives who were considered odd or eccentric or who had difficult personalities?” |
|
|
Term
| Past Developmental History |
|
Definition
• Tell me about your childhood
• A picture of patient’s early life—dyslexia/dyspraxia
• Family of origin
• Death
• Divorce
• Close-knit family
• Friends, hobbies, interests
• School—How far did the patient progress?
• Disciplinary problems
• Learning disabilities
• Frequent trips to the doctor
• Absences from school
• Abuse
• Bullying
• Bed-wetting, nightmares, night terrors, phobias
• Stuttering, tics
• Parental “rewarding” of illness behavior with attention can precede some somatoform disorders
• Eating disorders
• OCD
• Gender identity |
|
|
Term
|
Definition
• Employment—holding down a job, fired, quit, missing work, frequent job changes
• Military—PTSD
• Disability compensation
• Marital and love relationships; partner discord
• Children—health of children
• Has the patient avoided or fought with friends?
• Legal—police, court, jail (bipolar, SUD)
• Personal interests—lose interest in hobbies, sex, etc.
• Homeless? Living situation?
• Current financial situation—”Has money ever been a problem for you?”
• Leisure activity—loner?
• Support system/relationships with others/bereavement
• Religion
• Violence
• Seasonal affective disorder
• Social phobias
• Caffeine
• Tobacco
• ETOH
• Opiates (prescribed or street)
• Benzos
• Cocaine
• Meth
• PCP
• Stimulants
• Hallucinogens
• Ecstasy
• Marijuana |
|
|
Term
|
Definition
• Dating history
• Sexual issues begin
• Sexual or physical abuse
• Promiscuous—mania, STI
• Libido decreased—depression
• “Did you ever feel mistreated as a child?”
• Suffering childhood sexual or physical abuse can lead to somatization disorder, dissociation, PTSD, and personality disorders, among others
• Impotence, dyspareunia, premature (or delayed) ejaculation, infidelity, STDs, and concerns about possible homosexuality or bisexuality |
|
|
Term
|
Definition
• Children—health of children
• Problemsduringlabor
• Post-partum depression
• Abortions |
|
|
Term
|
Definition
• Vitals
• General, skin, HEENT, neck, chest/lungs, breasts, heart, abdomen, GU, musculoskeletal, neuro (CN, motor, sensation, gait, coordination, abnormal movements) |
|
|
Term
|
Definition
• Appearance—observed
• Level of consciousness/alertness (arousal)—observed
• Orientation—inquired
• Attention and concentration (attention span)—observed/inquired
• Speech and language—observed
• Behavior—observed
• Attitude—observed
• Mood—inquired
• Affect—observed
• Thought content—observed/inquired
• Thought process—observed/inquired
• Memory—observed/inquired
• Visual spatial perception—observed/inquired
• Higher cortical functioning and reasoning/executive function—observed/inquired
• Praxis—observed/inquired
• Calculations—observed/inquired
• Suicidality and homicidality—inquired
• Insight and judgment—observed/inquired |
|
|
Term
|
Definition
• Accucheck
• CBC, (anticonvulsants, some antipsychotics may alter)
• CMP (SSRIs, anticonvulsants may alter)
• Ca,Mg
• Drug screen
• ETOH level
• UA/U—pregnancy
• Kidney function tests BUN/Cr (lithium may alter)
• LFTs (anticonvulsants, antidepressants may alter)
• Thyroid panel (lithium may alter)
• Lipids (antipsychotics may alter)
• Ammonia
• Blood cultures |
|
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Term
| Objective Tests for psych |
|
Definition
• EKG, cardiac monitoring
• ABG (hypoxic)
• CXR (sepsis)
• CT scan
• MRI
• Lumbar puncture
• EEG
• NCT
• Neuropsychology testing
• Occupational therapy evaluation |
|
|
Term
|
Definition
• Biological (medical conditions, abnormal labs, substance use exposures, genetic/family risk)
• Psychological (past life experiences/ developmental issues, extent and depth of interpersonal relationships, central conflicts, transference/ countertransference,
psychological defenses)
• Social (stressors and supports within social context, cultural identity)
• ConsiderthefourP’s(assesspredisposing, precipitating, perpetuating, and
protecting factors)
• Summaryofriskassessment
• Strengthsofthepatient
• Differentialdiagnosis/supportiveevidencefor working diagnosis, appropriate treatment goals, prognostic factors |
|
|
Term
| Patient Education and Discharge |
|
Definition
• Court-ordered counseling
• Mandatory legal guardian of the state/case worker/parole officer
• Social work
• Case management
• Reassurance transferring to inpatient unit
• Patient safety (involuntary hold, 1:1 observation, restriction on possession of certain items, fall risk)
• Meals (may need special attention in delirious or severely demented patients due to aspiration risk; if on MAOI for depression, patient will need special dietary restriction of tyramine—rich foods)
• Additional appropriate PRN’s (agitation, anxiety, insomnia, acute psychosis, acute mania, pain, GI distress, nicotine/ETOH/drug W/D)
• Hold or D/C any outpatient medications that may complicate or be contributing to more acute problems (caution: possible W/D syndromes if sudden Rx D/C, especially with benzos) |
|
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Term
|
Definition
• Medication adherence
• Stop smoking, drugs, ETOH
• Explain drug-drug interactions
• Discuss the effects of long-term psychiatric medicine
• Finances
• Who does the patient want involved in their care
• Disposition planning (post-discharge housing, community support system/resources, providers, financial/transport access to health care)
• Family planning on psych meds |
|
|
Term
|
Definition
• Common
• Culturally-diverse
phenomenon
• Normal variation like left- handedness
• Not inherently pathological or negative. |
|
|
Term
| if gender diversity isn't pathological, disordered or an illness then waht are we treating |
|
Definition
| distress that impedes function is the target of the intervention not the patien'ts gender identity |
|
|
Term
|
Definition
• Transgender youth whose gender identity is affirmed are psychologically indistinguishable from cisgender controls
• Family Acceptance -> Resilience, +Psychological health and wellbeing
• Consistent Narrative |
|
|
Term
| Transgender Medicine in Primary Care |
|
Definition
Deferral of Puberty
Hormone Therapy
Second Letters Consultations
Pre-op Evaluation
Post-Op After Care
Timely Referrals
(Surgery, Speech Therapy, Electrolysis, etc.) |
|
|
Term
| Diagnostic Criteria (DSM-5/APA) for Gender Identity |
|
Definition
• Insistent, Consistent, Persistent
• x 6mo
• Incongruence with ASAB
-> Significant distress or problems functioning
• *Worsened with puberty
• Regardless of Differences of Sexual Development (intersex)
• Development determines presentation & management |
|
|
Term
| Treatment Criteria (SOC-7/WPATH) foer gender identity |
|
Definition
-Persistent, well-documented gender dysphoria;
-Capacity to make a fully informed decision and to consent for treatment*;
-Age of majority in a given country (if younger, follow the SOC sec VI);
-If significant medical or mental health concerns are present, they must be reasonably well-controlled* |
|
|
Term
| Referral for Treatment (SOC Letter) for dender identity |
|
Definition
1. The patient's general identifying characteristics.
2. The initial and evolving gender, sexual and other psychiatric diagnoses. This is to include Axis II diagnosis. Any psychiatric medications MUST be accompanied with a diagnosis. This area should discuss the patient's initial cross-gender feelings.
• •
• •
•
First memory of gender
First person that was told about your gender? How did it make you feel?
First person in family told about your gender? How did it make you feel?
If they’ve been through puberty, what was it like?
– Age of adrenarche, menarche, thelarche, etc
If they’re dating, did/do partners know their GI?
3. The duration of the author’s professional relationship, the type of psychotherapy or evaluation that the patient underwent, frequency of visits & patient compliance.
Screens: BDI, IPSM, Recalled childhood gender, HRT, HBIGDA
Evaluation for evidence of
• Thoughtdisorder
• Majoraffectivedisorder
• Psychosis
• Cognitivedeficits
• Impairmentofjudgementand insight
4. The eligibility criteria that have been met & the author’s rationale for hormone therapy/puberty suppression therapy/surgery
-Persistent, well-documented gender dysphoria;
-Capacity to make a fully informed decision and to consent for
treatment;
-Age of majority in a given country
(if younger, follow the SOC sec VI);
-If significant medical or mental health concerns are present, they must be reasonably well-controlled.
5. The degree to which the patient has
followed the SOC to date. The
likelihood of future compliance. Main
areas of transition should be covered
here and should include name change, history of gender presentation at
school and home. (Minors+: State all
parents/guardians are supportive &
willing to sign “consent for treatment”,
agreed to this approach & will attend initial OV. The author will continue to
see the minor+ on a regular basis.)
6. The author should list their experience
in treating TG clients. Include years of experience, number of clients treated
and currency of training in transgender
issues. List any TG organization
memberships and if they are part of a
gender team. (http://bit.ly/1nAQbsl) 7. The author welcomes a phone call to
verify the fact that the author actually wrote the letter as described in this document. |
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