Mary Ann Foley-Mayer DMH, RN, APN, C Family Psychiatric Mental Health Nurse Practitioner

1. Creative Approaches for Differentiating Medical From Psychiatric Symptoms Using Physical Assessment Skills Mary Ann Foley-Mayer DMH, RN, APN, C Family Psychiatric Mental Health Nurse Practitioner

2. Disclosures • No affiliations to disclose • The photos and video are from the internet and you tube and are all in public domain • All names are fictional • The case studies are from real client situations • None of the photos are from actual patients

3. Objectives • Describe symptom analysis and how to formulate a differential diagnosis using physical assessment skills. • Differentiate symptoms as medical or psychiatric based on case studies and visual aids • Discuss physical symptoms that may be induced by psychotropic medication

4. Practical Objectives • Quickly assess the client who just doesn’t look right • Utilize the practical physical assessment skills to decide if the situation is emergent • Direct or provide the necessary care • Plan ahead for emergencies • Gain information you can use in your daily practice while enhancing your critical thinking skills

5. Have you even had a client walk into your office who: • Has chest pain • Has an unexplained skin rash • Has tremors or unusual movements • Looks pale and shaky • Has a seizure • What do you do?

6. Topics • Cardiac vs anxiety/panic • Skin rash vs rash from psychotropic medications • Insomnia • Neurologic topics: seizure vs Psychogenic Non Epileptic Seizure, change in mental status • Medication induced physical symptoms

7. Physical Assessment • Health History • Inspection • Palpation • Auscultation • Percussion

8. Symptom Assessment Rule of Thumb • One symptom may not be serious • The more symptoms the more likely the situation is serious • Symptoms involving vital signs including blood pressure, pulse, respiration, acute pain, change in skin color are more serious

9. Develop an emergency plan • 911 • What agency do you use for emergency services? • Do you have a contact person in that agency? • Develop a network of primary care referrals you can send clients to in an emergency • Visit your local ED and crisis center to develop contacts

10. Cardiac vs. anxiety

11. Henry • 56 year old male treated for Major depression, grief related to the death of his wife and alcohol dependence in remission for the past year • Meds include: Citalopram 20mg and Quetiapine 50mg daily at bedtime. • He is complaining of a sharp pain in his left chest usually while sleeping.

12. Henry • Is he having an MI? • Could the pain be related to his psychotropic medication? • Is this an emergency? • Can we proceed with the psychiatric assessment or does he need acute medical treatment?

13. What if it’s cardiac? • A=airway • B= breathing • C=circulation • Skin-pallor, color, cyanosis, diaphoresis, edema • Question the client- chest pain, difficulty breathing, does he appear in distress, assess his ability to answer, any shortness of breath • Vital signs • Can the person focus and concentrate • Assess pain • Do I need to call 911?

14. Henry • His vital signs are normal and he is not in acute distress • Proceed with taking a history of the pain • Can continue with the psychiatric session as he is feeling well right now and is willing to continue

15. Henry • He went to the ED 5 months ago for this sharp pain. Chest x-ray showed a nodule of the left chest. • He saw his primary care practitioner and has an appointment for follow up • He takes Motrin for pain • He still has chest tightness and pain mainly at night and now is having headaches

16. Assessment of Symptoms • Chest tightness and pain usually while sleeping • Possible causes • Headache • Related to chest pain? • Look for the most logical or simplest causes

17. Henry • Not likely an MI as he has no pain or symptoms now, he was seen in the ED and by his PCP and a work up is in progress • Possible infection? Check blood work • Suspicious nodule in left chest- lung lesions due to infection or cancerous tumor? • Chest pain at night- possible GI etiology

18. Henry • Lung nodule determined benign and his practitioner is watching it. • He is now treated for GERD with relief of the night time chest pain • His headache was from using an old pair of bifocals instead of getting new prescription trifocals • He is doing well emotionally and denies feeling depressed • By taking the time to review the symptoms and possible etiology with Henry he became calmer and we ruled out any emergent situation.

19. Chest pain vs. Panic • You are seeing a client for the first time for a psychiatric symptom and have very little information about the person • This is how the client presents

20. What are your first thoughts? • Anxiety • Panic • Cardiac illness • Asthma • Physical illness

22. What are you priority assessments? • Airway, Breathing and Circulation • Is it necessary to call 911? • Current complaints of pain? • Does he/she look in distress? • What are the vital signs? • Conduct a pain assessment • Order blood work and EKG? • Send the patient to the ED?

23. Is the patient having chest pain? • Is it a life threatening condition? • Could it be pain from another system-pain from GI, musculoskeletal, respiratory, cardiac and pulmonary systems all transmit to the same spinal cord segments, T1-T5. • Life threatening illness includes MI, PE, pneumothorax and aortic dissection

24. Assessment of Pain • Timing, onset, duration, frequency • Anatomical location • Character or quality • Setting • Severity or intensity-Rating scales of 1-10 or happy and sad faces • Aggravating or alleviating factors • Associated symptoms • Client’s perception of the meaning of the symptoms

25. Serious Symptoms involve vital organs • Abnormal blood pressure, temperature, pulse or respiration • Cyanotic color changes • Sudden change in level of consciousness or mental status • Severe pain • Sudden and intense agitation or lethargy • These require immediate treatment

26. Assess • Vital signs • Pain level • Check the feet and ankles for edema • Listen to the person’s lungs- assess for wheezing, crackles, rhonchi, absence of breath sounds. • Auscultate for heart sounds

27. Sequence for Auscultating Begin with the diaphragm. • Note at each area: 1. rate & rhythm 2. identify S1 and S2 3. assess S1 and S2 separately 4. listen for extra heart sounds (ie. S3,S4) 5. listen for murmurs Repeat above using the bell. Listen for any irregular beats, skipped beats or tachycardia

29. Causes of an MI • Hypertension-causes chronic injury to the intimal lining of the coronary endothelium. • Low-density lipoproteins (LDL) are the source of most lipids in atherosclerotic plaques. • Diabetes, chemical irritants in tobacco smoke and infections cause injury to the lining of the coronary artery and plaque formation. • Thrombosis related to damage to vessel walls • The presence of damage to the intimal lining of the coronary artery changes the vessel size and interferes with homeostatic functions of the endothelium causing vasodilatation.

30. Causes of an MI • Disruption of a plaque can produce thrombosis creating a lesion. • This acute thrombus can produce complete or partial occlusion, which further impairs blood flow to the myocardium when coupled with vasospasm. • Microvascular disease, endothelial dysfunction, or both may contribute to impaired blood flow to the myocardium. • The duration and severity of blood flow impairment determines the severity of the acute coronary syndrome manifestations—unstable angina or myocardial infarction (MI).

31. MIPathophysiology • The major cause of MI is anatherosclerotic plaque impeding forward flow in a coronary artery. • In women, however, chest pain and abnormal stress tests can occur without a critical, flow-limiting lesion. • In the Women's Ischemia Syndrome Evaluation (WISE) study, nearly 60% of women with chest pain who underwent coronary angiography did not have a critical lesion (defined to be >50% luminal stenosis in a coronary artery). • Merz CN, Kelsey SF, Pepine CJ, et al. The Women's Ischemia Syndrome Evaluation (WISE) study: protocol design, methodology and feasibility report. J Am Coll Cardiol 1999;33:1453–1461.

32. MI Pathophysiology • In this study population, women without critical luminal narrowing had persistent symptoms despite usual therapy • They had worse outcomes than age-matched controls during the follow-up period of 4 to 5 years. • The persistence of symptoms coupled with abnormal stress test results has been attributed to endothelial dysfunction or microvascular disease. • Women have smaller coronary arteries than men, even after correcting for body surface area. • Women have been shown to be twice as likely as men to have plaque erosion with subsequent thrombus formation. • Coronary vasospasm affects women more frequently than men.

33. Symptoms of MI in women • Heart Attack Signs in Women • Uncomfortable pressure, squeezing, fullness or pain in the center of the chest. It lasts more than a few minutes, or goes away and comes back. • Pain or discomfort in one or both arms, the back, neck, jaw or stomach. • Shortness of breath with or without chest discomfort. • Other signs such as breaking out in a cold sweat, nausea or lightheadedness. • As with men, women’s most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain. • American Heart Association

34. Symptoms of MI in men

35. Symptoms of MI

36. Syncope

37. Assessment of Syncope • Reversible loss of consciousness and postural tone • Results from a sudden decrease in cerebral perfusion • Uncommon in children except in those with a seizure disorder, cardiac arrhythmia or behavioral issues such as breath holding • Can also be related to psychiatric illness • Syncope should always be evaluated for an underlying medical cause

38. Is it syncope related to orthostasis?ASSESS • Medications • Dehydration • Blood pressure changes • Diabetes can induce hypoglycemia resulting in syncope • Anemia and chronic GI bleeds • Pregnant patients on prolonged bed rest are prone to orthostasis and syncope

39. Is it syncope or “near syncope” • Did the person actually lose consciousness • Was there dizziness, vertigo or pre-syncope (feel faint but not actually lose consciousness) • Any prodromal symptoms – sweating, vertigo, nausea, yawning, aura (seizures and migraine headaches are often associated with an aura)

40. Psychiatric causes of Syncope • Psychogenic • Panic and anxiety • Somatization • Major depression • Substance abuse • Physical exam is usually negative but psychiatric exam reveals symptoms

41. Syncope- What to do? • Determine if the person needs to go to the ED • Ask the person what treatment they will accept- ie prefer to see own practitioner, no treatment • If they refuse treatment but they are still having symptoms advise the person you are calling 911 to have him assessed and provide support.

42. Skin Rash

43. Skin Rashes • Anxiety – causes stress and stress can cause a skin rash • Negative stress releases cortisol and adrenalin into the circulation causing a skin rash. • Stress also makes skin more sensitive to creams, sunscreen, and the sun causing skin rash. • Stress causes skin conditions such as Psoriasis, Eczema, Acne, Rosacea and Herpes to worsen.

44. Skin rashes • Anxiety producing • May be serious or benign • Can cause discomfort and fear • May be related to medication

45. Skin Rashes-How to identify a drug related skin rash • History • Was it present in the past? • Did it start when the drug was started? • Did it improve when the medication was stopped? • Where is the rash located? • Is the person bothered by the rash? • Could it be Stevens Johnson?

46. Stevens Johnson Syndrome • Stevens-Johnson syndrome is a rare, serious disorder in which skin and mucous membranes react severely to a medication or infection. • Often, Stevens-Johnson syndrome begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters, eventually causing the top layer of skin to die and shed. • Stevens-Johnson syndrome is an emergency medical condition that usually requires hospitalization. Treatment focuses on eliminating the underlying cause, controlling symptoms and minimizing complications. • Recovery after Stevens-Johnson syndrome can take weeks to months, depending on the severity of the condition. If the case of Stevens-Johnson syndrome was caused by medication, the patient needs to permanently avoid the medication and all others related to it. • MayoClinic.com

47. Skin Rash • Identify the location and distribution of the lesions (localized, regional, generalized.) • Is it a primary lesion or a secondary lesion (resulting from change in the primary lesion) • Identify the shape and arrangement of lesions • Describe the color, borders, pigmentation and variations of the lesions • Are there a few lesions or are they numerous and widespread • They are more serious if they are widespread and have additional symptoms such as fever, itching, bulla, flu like symptoms

48. Urticaria- hives

49. Dermatitis

50. Rash from Amoxicillin