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Agitated and combative patient

Clinical Discipline(s)/Organ System(s)
Clinical Biochemistry, Emergency Medicine, Psychiatry/Health Psychology
Progress Test Topic(s)
A 68 year old NZ European man, with no fixed abode, presents under police escort to the Emergency Department agitated and aggressive. He has presented on previous occasions as intoxicated on alcohol, sedated and non-confrontational. He has also sometimes presented with physical symptoms that can’t be medically explained with the hope of acquiring an overnight stay in hospital. However, on this presentation he has threatened to punch you and the nursing staff when you discussed the need for him to stay in the Emergency Department for further investigations.
Progress Test-Type Questions:   Question 1
Applied Science for Medicine 
   - Anatomy of the brain
   - Pathophysiology of delirium and dementia
   - Microbiology of herpes simplex virus
   - Role of drug intoxication and withdrawal in altered mental states
   - Awareness of nutritional deficiencies and how this may compound certain presentations e.g. delirium tremens
   - Pharmacology of haloperidol, olanzapine, rispiridone, benzodiazepines
Clinical and Communication Skills 
   - History from an agitated patient; elicit a collateral history; assess risk factors for delirium
   - Perform a general examination, as complete as is possible; recognise drug withdrawal and intoxication
   - Differential diagnosis of the aggressive patient, delirium
   - Indications for CT head, MRI brain, lumbar puncture
   - Perform capillary glucose level, measurement of blood pressure, lumbar puncture
   - Interpret full blood count, electrolytes, liver function tests, blood glucose level, calcium, thyroid function tests, vitamin B12/ B12 (NZF link) folate, toxicology screen, pathology report on cerebrospinal fluid (CSF), chest X-ray, syphilis serology, short synthacen test
   - Management of the challenging patient: pharmacological and non-pharmacological
   - Awareness of high mortality rates with delirium tremens and the medical treatments required for this
   - Role of security staff, levels of observation and de-escalation measures
   - Role of liaison psychiatry, social worker, nurse
   - Understand how medically unexplained physical symptoms can present
Personal and Professional Skills 
   - Deescalating an aggressive situation
   - Self-care: personal safety
   - Decision-making capacity
   - Best interests principle
   - Assent and consent
   - Legal aspects of compulsory assessment and treatment, Mental Health Act, Right 7(4) of the Health and Disability Commissioner’s Code of Rights
Hauora Māori 
   - Cultural safety in examining an agitated person
   - Access to cultural resources in an Emergency Department
   - Ethnic disparities in 'homelessness', mental disorder and alcohol/drug misuse
Population Health 
   - Epidemiology of delirium/acute confusion state, schizophrenia, substance abuse, substance withdrawal, herpes simplex virus, meningitis
   - Homelessness: reasons, support programmes, discrimination
Conditions to be considered relating to this scenario
subdural haemorrhage, psychosis of any cause, hypoglycaemia, hypoxia, hypo/hypernatraemia, urinary tract infection, hypercalcaemia, hypocalcaemia, concussion, vitamin B12/folate deficiency, hypothyroidism, delirium tremens, Wernicke's encephalopathy, acute coronary syndrome (STEMI, NSTEMI and unstable angina), intoxications, extradural haemorrhage
Less common but 'important not to miss'
cerebral tumour, tertiary syphilis, meningitis, encephalitis, subarachnoid haemorrhage
Whipple's disease, uraemic encephalopathy, hepatic encephalopathy, Addison's disease
Related Scenarios
[Self-harm], [Delirium / dementia]