The Psychiatric Emergency

Violence, drug abuse, alcoholism, psychoses, suicide attempts, confusional states and distress and fear are common presentations in ED with which you may not be familiar.      
A reassuring, orderly, calm approach will save time in the long run.
Obtain as comprehensive a history as possible from the patient, relatives, friends, the Gardai, social workers and ambulance personnel. A telephone call to the GP may be helpful.
Perform a physical and mental state examination, even though it may be difficult to obtain full co-operation. Record any difficulties experienced in taking a history or undertaking the examination. 

Try to avoid a brisk authoritarian or patronising attitude. Introduce yourself by name and address the patient courteously by name. Don’t return rudeness or aggression in kind. Whatever the patient may be saying try to emphasise help can be obtained. In some circumstances gentle physical contact such as touching the arm or feeling a pulse may be helpful if you are not alone with the patient,  History and examination are best carried out in a quiet room. Whatever the sex of the doctor or patient it is as well to have a nurse present unless the patient objects completely. Possibly a relative or friend if the patient wishes it.  
Note particularly: state of personal hygiene and clothing; smell of alcohol; scars, tattoo marks, bruises; wounds and injection marks; state of nutrition and hydration  
Mental state examination
- Level of consciousness
- Alert or Drowsy  
- Appearance and behaviour, degree of co-operation, suspiciousness, hostility, muttering,  
- Posture, eye contact  
- Speech
- Coherence , pressure or slowing of speech  
- Mood 
- Anxiety, fearfulness
- Depression, tearful, sleep problems, suicidal ideation, elation, anger, lability, concentration
- Thought content, repetitive thoughts, interference with thoughts, delusions, hallucinations esp. auditory or visual,  
- Insight.
- Cognitive function  
- Memory for recent and remote events, orientation in T,P,P. , short term recall  
It is important that good notes are made at the time of the examination.  
Objectives of assessment
A definitive psychiatric diagnosis is not the main objective. The ED doctor’s role is to appraise the crisis situation, institute appropriate management and arrange safe ongoing care. When confronted by the distressed, confused or behaviourally disturbed patient it will be important to answer the following questions:
-  Is organic disease or trauma responsible for the disorder?  
- If the patient shows disorientation, memory disturbance, visual hallucinations, or fluctuating levels of consciousness, it is likely that organic disease, trauma, drug intoxication or withdrawal is present. 
- Is the patient a danger to himself or others? He may be expressing suicidal ideas (or they may be elicited), homicidal feelings or intentions, or behaving aggressively. The SAD Persons Score may be of value in assessing risk.  
- Does the patient require admission to a psychiatric unit? 
- In what social context has the disturbance occurred and how far can relatives and friends be helped to cope with the situation?