Police bring a 63-year-old woman to the emergency room, reporting that her behavior is disorganized and disruptive, that her speech makes little sense, and that she does not seem able to take care of herself

Question

The woman has had elective surgeries at the hospital previously and was seen in the ER last week after a fall; records show no history of similar symptoms or mental illness. The ER physician speaks with the patient but does not examine her medically, diagnoses her with schizophrenia, and orders admission to the inpatient psychiatric unit. Which response by the nurse would be most appropriate? a. Ask another physician with more of an interest in psychiatry to also take a look at this patient, explaining that you just want to be as thorough as possible.
b. Suggest that a psychiatric consult be requested before admitting the patient to a psychiatric unit, to validate the diagnosis and speed the initiation of medication.
c. Remind the physician that schizophrenia usually develops earlier in life, that such presentations may be caused by medical problems, and suggest a medical work-up.
d. Note that the patient's blood pressure and respirations were elevated when she arrived, and suggest that they be evaluated before admitting the patient to the psychiatric unit.

Answer 1

C
As a matter of sound practice, all persons with what appears to be a first episode of mental illness should have a full medical workup so that contributing and concurrent medical issues can be ruled out or treated. In this case, the patient is past the age when schizophrenia usually develops, and she has had an acute onset of symptoms, which is inconsistent with schizophrenia. Both these factors suggest a possible medical origin for her mental status changes. Therefore, further medical assessment is needed, and the most direct and professional means of achieving this is to speak assertively with the physician, reminding him of the factors which merit a more complete medical evaluation before diagnosis. Involving another physician could create conflict among those involved and would not be professional. Achieving a further evaluation by involving a psychiatrist and/or focusing on secondary rationale (speeding up the initiation of psychiatric treatment, addressing vital sign abnormalities) is disingenuous and could misdirect the focus of the evaluation, allowing medical causes of the patient's presentation to again be overlooked.