MEDICAL CLEARANCE OF PSYCHIATRIC PATIENTS Physical Illness in Psychiatric Patients in a Psychiatric Inpatient Setting

increasing role in the provision of acute psychiatric care in recent years.1 Major factors accounting for this trend are the ongoing deinstitutionalization of mentally ill patients and the nationwide epidemic of substance abuse.1 Psychiatric patients may present to the ED with various disorders that may include functional or toxic/metabolic psychosis, the behavioral side effects of medications, complications of substance abuse, and coexisting medical and psychiatric illnesses. Delirium and dementia are the most frequent non–drug related nonfunctional causes of psychosis seen in the ED. Caring for psychotic patients presents special challenges because the history in these patients is often poor or unobtainable. In addition, such patients lack insight into their illness and may present with bizarre affect, agitation, and violent behavior. This article discusses the evaluation and management of psychotic patients in the ED in terms of physical illness in the psychiatric patient; screening for medical and psychiatric illness; history and physical examination; management of the violent, agitated, or disruptive patient; and psychiatric evaluation. Substance abuse in this patient population is also discussed.