Consultation-Liaison and Emergency Psychiatry
This domain tests rapid risk assessment, safe management of agitation, and recognition of psychiatric presentations of physical illness. The examination favours questions where the wrong answer treats the behaviour and the right answer finds the cause.
Emergency assessment
In acute agitation, start with verbal de-escalation, a safe environment and an offer of oral medication. If parenteral treatment is required, use a recognised rapid tranquillisation protocol with monitoring of pulse, blood pressure, temperature, oxygen saturation and consciousness. Avoid combining intramuscular olanzapine with parenteral benzodiazepines because of cardiorespiratory collapse. Always look for hypoglycaemia, hypoxia, head injury, sepsis, anticholinergic toxicity and drug intoxication before labelling agitation as psychiatric.
Deliberate self-harm
Assess method, lethality, intent, planning, precautions against discovery, precipitants, previous attempts, mental state, substance use, social support and protective factors. Psychosocial assessment before discharge reduces repetition, and brief contact follow-up has evidence for reducing repeat self-harm. A statement that the patient denies suicidal ideation is not a risk assessment.
Distinguishing syndromes
Serotonin syndrome: clonus, hyperreflexia, agitation, sweating, diarrhoea, onset within hours of a serotonergic agent. Neuroleptic malignant syndrome: lead-pipe rigidity, hyperthermia, autonomic instability, raised creatine kinase, onset over days. Catatonia: stupor, mutism, posturing, waxy flexibility, negativism, responding to a lorazepam challenge, with ECT for refractory cases. Acute dystonia responds to procyclidine or benztropine.
Worked example
A 40-year-old admitted with pneumonia becomes agitated at night and pulls out his cannula. Reasoning: new agitation in a medically ill patient is delirium until excluded, so the first steps are oxygen saturation, glucose, electrolytes, infection markers, pain assessment and a drug chart review for anticholinergics and steroids. Physical restraint without treating the cause, or discharge, would both be wrong.
Traps that cost marks
Failing to medically clear a patient before psychiatric admission. Missing an organic cause of first-episode psychosis in the emergency department. Discharging after self-harm without psychosocial assessment. Over-sedating rather than diagnosing. Ignoring the physical health of patients with severe mental illness.