Extreme changes in body temperature in psychiatric inpatients should be a cause for concern. Depending on the working diagnosis and initial treatment, fever can be an early sign of an impending disease process, with accompanying morbidity and mortality. Even temperature elevations that are not extreme, including those to about 100.4°F (38.0°C), warrant timely evaluation. In any patient on antipsychotic medication with an unrevealing fever work-up and…

Background Nausea is a subjective sensation of gastric discomfort resulting in aversion to oral intake. This is associated with the behavioral drive to remove the noxious ingestant by vomiting. These two related symptoms are relatively nonspecific and can arise from a variety of causes, including primary gastrointestinal disease, central nervous system disorders, endocrine and metabolic disorders, systemic illness, disorders of the thorax, as well as adverse…

Phone call Questions 1. What are the patient’s vital signs? Have they changed? 2. Is the patient dyspneic, diaphoretic, or tachypneic? 3. When did the pain begin? How does the patient describe it? How does it relate to eating or position? 4. Does the patient have a history of cardiovascular disease (myocardial infarction [MI], coronary artery disease, angina), cardiac risk factors (e.g., hypertension, hyperlipidemia, smoker), gastroesophageal…

Headaches are a common complaint on a psychiatric service and may be a symptom of a serious medical condition or a manifestation of a psychiatric disorder such as anxiety or depression. Primarily, headaches have been classified into two categories depending upon the etiology: (1) primary headaches that are recurrent and chronic in nature, and (2) secondary headaches that result from a known central nervous system (CNS)…

Insomnia is often a symptom of another disorder. The key to treating insomnia is to search for the underlying cause. As with any consultation, each patient deserves a complete evaluation and appropriate treatment. It is tempting to quickly prescribe sedating medications for patients complaining of sleeplessness, especially if you are fatigued. Beware of medicating patients for insomnia, however, without first assessing them. This will avoid inappropriate…

Substance withdrawal is commonly encountered in both psychiatric and medical patients. The psychiatrist on call is asked to evaluate and treat patients who are behaviorally difficult, have comorbid psychiatric diagnoses, suffer clinical stigmata of withdrawal, and/or complain of various subjective discomforts related to the substance(s) from which they are withdrawing. Primary concerns for substance withdrawal include medical and psychiatric stability, and identification of the specific substance(s)…

Substance abuse evaluation is an important component of a thorough psychiatric interview. Our understanding of the neurobiologic mechanisms of addiction has progressed rapidly. Although we now have a more complex understanding of the intricacies of substance use and substance-induced disorders, evaluating and treating an intoxicated patient remain the most challenging situations to the psychiatrist on call. Often intoxicated patients are behaviorally difficult and may present with…

The psychiatrist on call may be asked to assess and manage the pregnant patient. In managing a peripartum patient, providers must be cognizant that treatment decisions affect both mother and the developing fetus. The on-call psychiatrist must carefully weigh the risks of treatment with psychiatric medications in pregnancy and lactation against the risks of untreated symptoms, which may include agitation, psychosis, mania, severe depression, functional impairments,…

Victims of trauma may require urgent medical and psychiatric attention. Here, trauma is defined as “exposure to actual or threatened death, serious injury, or sexual violence,” as defined by criterion A for post-traumatic stress and acute stress disorders in Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V). This chapter is a brief guide for the psychiatric consultant on how to provide psychiatric intervention in…

The on-call evaluation of new, acute changes in speech or communication requires consideration of a broad differential diagnosis. Changes in speech and language may be caused by various psychiatric, medical, and neurologic etiologies. There are a variety of deficits in speech, ranging from dysarthria to complete mutism, that must be differentiated from pathologic changes in cerebral language areas of the brain, as seen in aphasia. The…

Psychiatrists on call often evaluate patients’ complaints of stiffness, tremor, rigidity, and other abnormal movements. The causes vary, and the clinician should be prepared to manage both commonly encountered and reversible problems such as acute dystonia and more lethal conditions such as neuroleptic malignant syndrome (NMS). Although the more common problems represent some of the most dramatic presentations in the field of psychiatry, they can often…

A patient’s confusion in the general medical setting is most often a result of delirium or dementia. Delirium indicates the presence of an acute underlying medical problem (or combination of problems). Less commonly, confusion may be due to conditions such as pseudodementia and amnestic syndrome. It is important to distinguish between delirium and dementia to initiate appropriate medical treatment while trying to reduce the anxiety and…

When considering the psychotic patient in the hospitalized setting, it is helpful to recall that while psychosis is a characteristic of some psychiatric disorders (e.g., schizophrenia, schizoaffective disorder, mood disorders with psychotic features), not every patient with psychosis has a primary psychiatric condition: indeed, psychosis is a general descriptive term for a phenomenon that may be present in multiple medical and substance-related conditions, many of them…

Helping a team manage suicidal patients is one of the most important tasks of the psychiatrist. It is also one of the most anxiety-provoking situations we face. Expect powerful emotional responses from the patient’s family, hospital staff, and yourself. When on call in the hospital, you may be asked to assess suicidal patients in various settings including the emergency room, inpatient psychiatric unit, and inpatient medical…