Psychiatric Consultation to Medical and Surgical Patients

Speak with the Consultee

Rarely does the referring physician's stated request for consultation tell the entire story of why the primary caretakers want or need assistance from a psychiatrist. More often, the stated request is effectively a “calling card” to get the psychiatrist to come, a label signifying the team recognizes that something is psychologically amiss with the patient but about which they cannot be more specific. Only in speaking directly with the consultee will the consultant figure this out and determine what the “real” problem is.

Review the Record

Busy consultants should resist the temptation to allow the referring physician's synopsis of the patient's medical history and hospital course to substitute for a thorough review of the hospital record. Often the written and electronic records contain important data the referring physician may not even be aware of or pay attention to. For example, notes from nurses, nutritionists, and physical, occupational, and speech therapists frequently prove invaluable in assessing a patient's affective, behavioral, and cognitive states. Of all the patient's physicians, the psychiatric consultant may be the only physician to study these important entries. Ambulance “run” sheets and emergency department notes are also helpful. For example, knowing whether the patient initiated or cooperated with the process of getting to the hospital can be hugely useful in capacity evaluations and in assessments after suicide attempts. Anesthesia flow sheets may reveal periods of hypotension or hypoxia during an operative procedure, suggesting the occurrence of clinically-significant cerebral hypoperfusion. In most instances, previous records do not have to be reviewed quite as exhaustively, but electronic medical records (EMRs) have enhanced the ease of doing so; the consultant wishing to avoid reinventing the wheel is well advised to take advantage of them.

Review Medications

The most definitive way to determine the medications the patient is actually receiving is a thorough review of the medication administration record (MAR). Computerized and handwritten order entries convey only the medications the patient is ordered to receive, not the agents he or she actually received. In reviewing the MAR, standing, as-needed, and one-time orders should be examined in order to capture a complete appraisal of the patient's treatment. This scrutiny is particularly useful in tracking alcohol detoxification, levels of sedation and agitation in delirium, and suspected “medication seeking.” Attention should also be paid to medications the patient has recently stopped taking or has had erroneously continued. While “medication reconciliation” has never been easier or more emphasized than it currently is, clinical laxity should be resisted. For certain classes of medications, such oversight can cause mental status aberrations of relevance to the consulting psychiatrist. For example, a benzodiazepine a patient has received for several weeks while in the intensive care unit may be mistakenly discontinued when the patient is transferred to a regular nursing unit, thereby precipitating acute benzodiazepine withdrawal.

Gather Information from Family and Others

Patients in the general hospital are frequently poor historians. Because of delirium, dementia, substance intoxication or withdrawal, and sundry other causes of altered mental status, patients evaluated by psychiatric consultants may be unable to report the details of their medical and psychiatric histories (“they can't ”). For various other reasons (e.g., personality disorder, factitious disorder, malingering, shame, or misguided modesty), patients may be unwilling to divulge personal data (“they won't ”). In these cases, information from collateral sources (e.g., family, friends, primary care physician, previous treaters, and old records) is invaluable. However, information from these collateral sources is not necessarily more reliable or more valid than data gleaned from the patient. Therefore, no one source of information should be prized over any other.

Interview the Patient

The psychiatric interview of a patient in the general hospital is identical in principle to that performed in most other venues. Areas of inquiry are identified; a diagnosis is pursued; and contributing factors from other aspects of the patient's background, current circumstances, and personal characteristics are elicited. A longitudinal conceptualization of the problem is useful ( Figure 54-1 ). Thorough description of the presenting problem should be followed by an appraisal of the patient's psychological baseline. The patient should be asked when she last felt like her “usual self” rather than when she last felt “normal” or “good,” since some patients do not view themselves in these terms. Descriptions of that time should be provided and detailed questions should be asked (e.g., “How did you spend your time then?” and “Would I notice a difference about you if I met you then?”). The patient should be invited to speculate on how her “usual self” might cope differently with her medical situation. If the answer is “the same,” this provides an opportunity to explore characterological vulnerabilities. If not, this becomes an opportunity to look at intervening psychopathology or at demoralization. Next, triggers or harbinger symptoms of the presenting problem are identified. Lastly, a history of similar problems in the past is elicited. While many patients cannot be interviewed in such an orderly fashion, the history can still be organized this way in the note.

A schema for understanding the scope of the consulting psychiatrist's interview is presented in Figure 54-2 . Although the consultee's question must be kept in mind throughout the interview, consultees often misidentify psychopathology and thus the consultation question should be taken only as a suggestion. At the same time, the psychiatrist should not function as the local “biopsychosocial expert,” for whom just about anything in the patient's life is worthy of attention. Rather, the consultant generally situates himself or herself just outside the border of the “ missed by consultee ” circle and just inside the “ important — but not acutely ” circle. Keeping the interview in this area requires clinical judgment beyond simply “being biopsychosocial.” For example, a patient with acute apathy after a stroke has very different needs from the patient with obsessive-compulsive tendencies who is driving his family and the hospital staff to distraction after a hip replacement ( Figure 54-3 ).

Conduct a Mental Status Examination

There are no unexaminable patients in consultation psychiatry. Even a profoundly delirious patient who cannot maintain alertness can have his level of arousal assessed. Non-cognitive aspects of the mental status examination (MSE) are the same as in routine psychiatric practice and are discussed in Chapter 2 . This section focuses on principles of neuropsychological assessment and screening. We use the term screening to distinguish what the physician does at the patient's bedside from testing, a more rigorous and quantitative task usually performed by a neuropsychologist.

Neuropsychological assessment of the hospitalized patient begins not with specific screens, but with the interview itself. Acutely ill patients may be unmotivated to engage in a cognitive screening battery. Since motivation plays a key role in task performance, the consultation psychiatrist closely observes the patient's spontaneous processes, and subtly evokes them during the interview. For example, the patient who can discuss the up-to-the-minute details of her hospital course yet recalls none of the three items on the Folstein Mini-Mental State Examination (MMSE) does not have severe anterograde amnesia.

A fundamental principle of neuropsychological assessment is that mental functions are hierarchical: that is, some functions cannot be assessed validly if the faculties “above” them are disrupted. The broadest distinction in this ranking is that of state-dependent versus channel-dependent functions. State-dependent functions include arousal, attention, and motivation. Subordinate to these are channel-dependent functions, comprising language, prosody, visuospatial function, executive function, praxis, comportment, and the various forms of memory ( Figure 54-4 ). We now briefly review the state-dependent functions and those channel-dependent functions that are of particular value to the consulting psychiatrist. Table 54-1 gives a summary.

Attention

Attention and concentration refer to the abilities to engage appropriate stimuli without distraction by irrelevant inputs. Working memory refers to the ability to hold and manipulate selected information. Executive function involves response selection and guides the “work” of working memory. These three cognitive functions share dorsolateral-prefrontal-subcortical circuitry. The complex overlap among them is simplified in Figure 54-5 . Assessment of attention begins with simple observation of the patient during the interview while watching for distraction by extraneous internal or external stimuli. Forward digit span is the gold standard for screening attention at the bedside. Backward digit span or backward recitation of over-learned information (e.g., months of the year) uses information that is less influenced by education or culture than is a spelling or a mathematical task. The cognitive “work” required is simple, and, though it invokes working memory, we see it as occupying the overlap area in Figure 54-5 .