MRCPsych CASC: Assessment of an aggressive Patient in the Emergency Department

Scenario:

A patient with a severe psychiatric disorder has become aggressive. You have been called to assess him in the psychiatric emergency department. 

Introduction 

Assessing a patient with a severe psychiatric disorder can be a challenging task, especially if the patient is aggressive. It is essential to approach the assessment with caution and to prioritize the safety of both the patient and the assessing psychiatrist. Here are the steps for assessing a patient with a severe psychiatric disorder:

Establish rapport: 

The first step is to establish a rapport with the patient. This can be done by introducing oneself and explaining the purpose of the assessment. For example, the trainee psychiatrist can say, "Hello, I am Dr. [Name]. I am here to talk to you and assess how you are feeling."

Gather information:

The next step is to gather information about the patient's current symptoms and past medical history. This can be done by asking open-ended questions, such as "Can you tell me about your symptoms?" or "What led you to come to the emergency department today?"

Assess the patient's level of agitation:

The trainee psychiatrist should assess the patient's level of agitation by observing their behavior, body language, and speech. This can help to determine the level of risk the patient poses and whether additional safety measures, such as restraints, are needed.

Assess for suicidal and homicidal ideation:

The trainee psychiatrist should also assess the patient for suicidal and homicidal ideation by asking questions such as "Have you been thinking about hurting yourself or others?" or "Do you have any plans to harm yourself or others?"

Conduct a mental status examination:

 
The trainee psychiatrist should conduct a mental status examination, which includes assessment of the patient's mood, affect, thought process, and cognitive functioning. This can help to diagnose any underlying psychiatric disorders and determine the patient's level of functioning.

Make a diagnosis:

Based on the information gathered, the trainee psychiatrist should make a diagnosis and develop a treatment plan.

Sample Conversation

Here is a sample conversation between the trainee psychiatrist and the patient:

Trainee psychiatrist: "Hello, I am Dr. [Name]. I am here to talk to you and assess how you are feeling."

Patient: "I don't want to talk to you. Just leave me alone."

Trainee psychiatrist: "I understand that you may not feel like talking, but it's important that I assess how you're feeling to determine the best course of treatment. Can you tell me what led you to come to the emergency department today?"

Patient: "I just can't handle it anymore. Everything is too much."

Trainee psychiatrist: "I'm sorry to hear that. Can you tell me more about what's been bothering you? Have you been having any thoughts of hurting yourself or others?"

Patient: "Yes, I have been thinking about hurting myself."

Trainee psychiatrist: "Thank you for telling me that. I am here to help. I am going to make sure you get the care you need to feel better."

This is just a sample conversation and the exact questions and responses will vary based on the specific patient and their situation. The trainee psychiatrist should adapt the conversation to fit the patient's needs and level of cooperation.