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BASIC SKILLS FOR INPATIENT PSYCHIATRY

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BASIC SKILLS FOR INPATIENT PSYCHIATRY AHMED ELAGHOURY Egyptian & Arab Boards in Psychiatry Abbassia Hospital for Mental Health, MOH Cairo, Egypt


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WHY? Psychiatry started as “inpatient” practice eg Kraepelin, Khalboum, Bleuler Basic residency tasks Not available in many mental health facilities in Egypt Still current practice is affected by “mind-body” dualism, so psychiatrists may work in poor-facility hospitals deprived from other medical services / coverage ie depend on their skills in inpatient care Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 2


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Outline Admission process Working DD Initial assessments / orders Management plan Followup / Progress notes Psychopharmacology Discharge plan / arrangement Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 3


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Admission process Cairo, Dec 2014 4 BASIC SKILLS FOR INPATIENT PSYCHIATRY


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Type of admission according to Egyptian MHA Source / Through Supervisor psychiatrist: responsible Accurate record of date and time with clear physician name Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 5


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Working DD Cairo, Dec 2014 6 BASIC SKILLS FOR INPATIENT PSYCHIATRY


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Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 7 Donnely T & Giza C: Differential diagnosis mnemonics. 2001, Hanley & Belfus, Inc


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How to set a DD list? Phenomenology Age of onset OCD: onset, course, duration Risk factors: 3Ps Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 8


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Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 9 Byrne P & Byrne N: Psychiatry : clinical cases uncovered. 2008, Wiley-Blackwell


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Psychotic ds & Mood ds present the same Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 10 ICD 10 symptom checklist, WHO 1994


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Delirium Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 11 Donnely T & Giza C: Differential diagnosis mnemonics. 2001, Hanley & Belfus, Inc


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Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 12 Donnely T & Giza C: Differential diagnosis mnemonics. 2001, Hanley & Belfus, Inc


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Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 13 Donnely T & Giza C: Differential diagnosis mnemonics. 2001, Hanley & Belfus, Inc


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Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 14 Donnely T & Giza C: Differential diagnosis mnemonics. 2001, Hanley & Belfus, Inc


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Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 15 Donnely T & Giza C: Differential diagnosis mnemonics. 2001, Hanley & Belfus, Inc


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Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 16 Donnely T & Giza C: Differential diagnosis mnemonics. 2001, Hanley & Belfus, Inc


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Initial assessments / orders Cairo, Dec 2014 17 BASIC SKILLS FOR INPATIENT PSYCHIATRY


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All admitted pt to mental health hospitals should be assessed by: Security / Nurse aide / Nurse Internal medicine Clinical psychology Social worker Neuro exam: Cognitive Gait Motor CNs: (2, 3, 4 , 6), 7, (9, 10, 11) DTRs: bi, tri, ankle, knee / Superficial: plantar Coordination Stretch signs Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 18


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Initial orders regards: Vital signs Diet: regular / diabetic / cardiac / easy to chew & swallow Elimination: stool & urine Activity: with help / walking stick etc Precautions against: Fall / Aspiration / Seizures / VTE ECG / Labs / Imaging Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 19


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General tips Avoid crystalloids without I / O monitor Avoid D5W without thiamine PRN medications: as needed STAT medications: you must attend qHS medications: at bedtime Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 20


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Do NOT give conflicting order ( 2 connected orders in same phrase) eg PRN Chlorpromazine 50mg IM if BP ? 90 / 60 Monitor pt meals, except when sedated / confused [ - PRN Chlorpromazine 50mg IM – Notify if BP ? 90 / 60 ] [ - PRN haloperidol 10 IM – Do NOT exceed 50mg / d] [ - Notify if RBG ? 200 mg / dl] [-Monitor pt meals –Notify if pt is oversedated – Notify if meals are left as same] Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 21


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Labs & Imaging Cairo, Dec 2014 22 BASIC SKILLS FOR INPATIENT PSYCHIATRY


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Common labs CBC, LFT, KFT, Chemistry, TFT PRL Vit D3 & B12 Hepatitis viral markers / HIV Tumor markers Immune profile Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 23


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CBC & BMP Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 24


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QTc Interval Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 25 Quick LabRef app. Nika Informatics, 2014


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Management plan Cairo, Dec 2014 26 BASIC SKILLS FOR INPATIENT PSYCHIATRY


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Acute / Short term Long term Durations Scales / outcome measures Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 27


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Followup / Progress notes Cairo, Dec 2014 28 BASIC SKILLS FOR INPATIENT PSYCHIATRY


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MSE is a part of followup note Nurse’s observation Ward behaviors toward staff / other pts Side effects of medications Trace initial target symptoms Examples & discussion Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 29


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Psychopharmacology Cairo, Dec 2014 30 BASIC SKILLS FOR INPATIENT PSYCHIATRY


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Route of drug delivery Oral Parenteral: IM, IV Enteral: NGT, G tube, PR Inhalational Sublingual Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 31


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Unknown pt Who? Recently admitted without proper data regards previous mental / medical / drug Hx Pt in other health facilities Drug naive pt What to do? Avoid depot inj at start Avoid frequent daily dosing Avoid high doses Start low & go slow Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 32


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Depot injections Poor Compliance is main indication Start during inpatient stay: at least 2 wks before discharge Oral first Challenge doses Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 33


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Agitated pt Try know cause: psychotic / not Containment & calming down Follow predetermined protocol: drugs & how to after monitor? Eg Haloperidol , Olanzapine, Zuclopentixol inj Eg BZD inj Try avoid IV inj esp in poor facility hospitals Keep alert to oversedation: dehydration, hypoglycemia, aspiration, constipation etc Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 34


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Discharge plan / arrangement Discharge summary Final diagnosis Drug treatment OPD appointments Special precautions to pt / family Rehab arrangements Keep contacts of critical pts, esp in poor-record systems Cairo, Dec 2014 BASIC SKILLS FOR INPATIENT PSYCHIATRY 35


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