1. 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

2. 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.

3. Goals Standardized Medical Screening For the Behavioral Health Patient
Appropriate Laboratory Testing
Understanding EMTALA Rules
Standard Transfer Protocols

4. Goals Safe and Appropriate Patient Disposition
Adequate Documentation of Psychiatric and Co-existent Medical Diagnoses
Accurate Communication of Findings To Psychiatric Unit and Facility
Minimize the time to disposition of patient
Minimize the cost of the screening exam

5. 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?

6. Types of Patients Type 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)

7. Pitfalls Negative Counter Transference Intoxication and Withdrawal
Fundamental Attribution Error

8. Differential Diagnoses
Delirium
Dementia
Psychosis

9. Delirium Intracranial Disease Systemic Disease with CNS Involvement
Substance Abuse Withdrawal
Toxic Exposures

10. Dementia Gradual Loss of Cognitive Abilities
Clear Level of Consciousness
Non-Fluctuating over The Day
Primary Deficit—Impaired Short Term Memory

11. Psychosis—Organic Causes
Age greater than 40
New Diagnosis of Psychosis
Abnormal Vital Signs
Recent Memory Loss
Clouded Consciousness

12. Vital Signs
Blood Pressure
Pulse
Temperature
Oxygenation Assessment

13. 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)

14. Physical Findings Vital Signs Eye—EOM and Fundoscopic
Appearance (Grooming)
Level of Attention
Affect
Eye Contact
Speech
Signs of Head Trauma
Eye—EOM and Fundoscopic
Neck Exam—Nuchal Rigidity and Thyroid Enlargement
Chest Exam-Pneumonia, CHF, or Arrhythmias
Stigmata of Cirrhosis
Skin—Cold Clammy, Hot and Sticky

15. Mental Status Exam
Orientation
Mood
Affect
Memory
Language
Attention
Calculation
Abstraction
General Information
Judgments
Thoughts

16. Brief Mental Status Examination

17. Laboratory Testing Current Regimen
TFT (TSH)
RPR or VDRL
PT/PTT
Chest X-Ray
EKG
Blood Alcohol Level
CBC
Complete Metabolic Profile
Urinalysis
Urine or Serum B-HCG
Urine Toxicology Screen

18. Criteria For Laboratory Testing
Age Greater Than 40
New Onset Psychiatric Complaint
Abnormal Vital Signs
Abnormal Physical Findings
Abnormal Neurological or Mental Status Exams

19. Memory Activity Distortion Feelings Orientation Cognition
MADFOCS Differentiation Between the Organic and the Psychiatric Patient
Memory
Activity
Distortion
Feelings
Orientation
Cognition
Some Other Findings

20. MADFOCS Mnemonic

21. Physical Examination—50% Mental Status Examination—72%
Sensitivity of Detecting Medical Issues in the Behavioral Health Patient
History—94%
Physical Examination—50%
Mental Status Examination—72%
Laboratory Assessment--<50%

22. Disposition of Patients
Type 1—BHO: Referral to In-Patient or Out-Patient 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

23. 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

24. 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

25. References
Lemonick, MD, David M., “Conducting Medical Clearance of the Psychiatric Patient”, Emergency Medicine, March, 2006, pp