Why is the patient in hospital and what question or issue are you seeking help with? (I.e. do you want phone advice, do you need an urgent review, is it a diagnostic or management issue?)
Providing this information right at the beginning helps orientate the registrar and will help them hone in on specific information you present.
Report Mental Health Act Status: Is the patient scheduled, specialled, on a community treatment order or known to a psychiatrist?
Assess risk of harm to self or others. If patient is deteriorating rapidly, get help and consult early.
Perform basic MSE – are they currently co-operative, over-sedated, agitated, aggressive?
Context: What has happened, why has it led to hospitalisation? What is the primary condition being treated and the medical team’s current plan for investigations/prescription and length of stay?
Past psychiatric history and any provisional diagnosis.
If they have community psychiatry input?
What medications does the patient usually take? Are they taking these?
MSE – a generic comment about behaviour may be most useful over the phone. For example: is the patient withdrawn/interactive/cooperative/uncooperative/aggressive/confused/threatening staff/needing to be specialled (one-on-one nursing care), brief cognitive assessment to screen for delirium (orientation to person, place and time, patient able to recite months of the year backwards).
Investigations where relevant:
Urine drug screen and urinalysis.
ECG: Psychotropic agents may prolong QT interval and lead to ventricular arrhythmias.
EUC: check for hyponatraemia caused by SSRI or renal injury.
FBC to check WCC or CRP if delirium suspected.
Serum levels for medication such as lithium, sodium valproate, clozapine.
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