Emergency medicine clinics of North America
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Emerg. Med. Clin. North Am. · Feb 2024
ReviewLegal and Ethical Considerations in Psychiatric Emergencies.
Individual rights can be limited in the context of psychiatric emergencies. The emergency physician should be familiar with state laws pertaining to involuntary holds. Physicians are equipped to perform a medical screening examination, address mental health concerns, and lead efforts to de-escalate agitation. The physician should conduct a thorough assessment and distinguish between malingering and mental health decompensation, when appropriate.
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Hyperactive delirium with severe agitation is a clinical syndrome of altered mental status, psychomotor agitation, and a hyperadrenergic state. The underlying pathophysiology is variable and often results from sympathomimetic abuse, psychiatric disease, sedative-hypnotic withdrawal, and metabolic derangement. ⋯ Safety of the patient and of the medical providers is paramount and the emergency department should be prepared to manage these patients with adequate staffing, restraints, and pharmacologic sedatives. Treatment with benzodiazepines, antipsychotics, or ketamine is recommended, followed by airway protection, supportive measures, and cooling of hyperthermia.
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Schizophrenia is a chronic condition characterized by positive symptoms (auditory hallucinations, delusion), negative symptoms (avolition, social withdrawal), and disorganized thoughts/behaviors. Although the pathophysiology is incompletely understood, several neurobiological mechanisms have been proposed. ⋯ Patients should be assessed for suicide risk, violence risk, inability to care for self, and the risk of being the victim of a crime. Persons with schizophrenia are at an increased risk of substance use and a variety of medical problems.
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Emerg. Med. Clin. North Am. · Feb 2024
ReviewDifficult Patients: Malingerers, Feigners, Chronic Complainers, and Real Imposters.
Malingering is the intentional production of false or grossly exaggerated symptoms motivated by internal and external incentives. The true incidence of malingering in the emergency department is unknown because of the difficulty of identifying whether patients are fabricating their symptoms. ⋯ Several case studies are presented and analyzed from a medical ethics perspective. Practical recommendations include use of the NEAL (neutral, empathetic, and avoid labeling) strategy when caring for patients suspected of malingering.
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Depressive disorders encompass a spectrum of diagnoses and are more common in women and transgender individuals. Diagnosis involves thorough history-taking and exclusion of underlying medical disorders. The emergency physician should assess the risk of self-harm and consider environmental and social factors prior to disposition.