Things to do on your psychiatry rotation

I wanted to document some things I learned in hopes that it will be helpful to other med students.

– ALWAYS do a suicide risk assessment. That doesn’t just mean “do you feel like killing yourself?” Other questions that also need to be asked include “are you occupied with thoughts of death?” and “do you ever wish you were dead?” as well as whether they have any plans, means, previous attempts.

-Antipsychotics drug side effects are things you want to be very wary of. For example, check thyroid function and kidney function, etc. if they are taking lithium.

– Anti-convulsants are often used as antipsychotics/mood stabilizers.  that information was new to me and confused me a little.

– Assess cognitive function for kids with behavioral problems. they may be refusing to do their homework because they think it’s hard and get frustrated with the level of difficulty.

– Psych emphasizes heavily on the social history. that means if they’re working and what they do, where they live, whom they live with, who they rely on for their social support system, etc.

– Specifically ask about marijuana. Though weed is technically considered a “recreational drug,” many patients do not put it in the drug category and will say no when asked whether they do any drugs. Thus, it’s important to specifically ask whether they smoke weed.

 Taking the substance use history. A thorough history includes: when they first used the substance, how frequently and how much they’re using, their most recent substance use, their longest period of sobriety and when that was, what caused the relapse, the purpose of using the substance (while this seems trivial, it is important to know if they self medicate their depression for alcohol or other reasons), and if they’ve gotten into any legal trouble relate to the substance use. Regarding street drugs, you ask how much money they spend on it.

– Don’t just take their word for it, ask specific symptoms. many people “think” they’re depressed or bipolar, but when further questioned about the specific symptoms they experience, it meets none of the DSM criteria.

– Other parts of the history include any past history of brain injury, seizures. also try to ask about physical/verbal/sexual abuse, childhood milestones, family history of mental illnesses.

– Depression and bipolar disorders are two of the most common mental illnesses you’ll likely see, so read up a lot on those.

– Make the interview conversational instead of having a list to complete for the history taking. While it is still important to get a full history, it doesn’t have to go in a particular order. Try to make the conversation flow naturally. For example, when they say they do xyz drugs, you can easily transition from “how much do you spend on drugs” to “what do you do for a living or how do you pay for the drugs?”

– You don’t actually formally conduct a mental status exam during the interview, it’s mostly just based on your observation- so not even the “where are you, what are you here for, etc.” to test for whether they’re alert and oriented to person time place. Also, most of the time you don’t do the cognitive function exam to assess their immediate/recent/remote memory unless relevant (e.g. they’re old, had previous brain injury). At least for me, I initially thought you did that on EVERYone.

– Learn the terminology early on. i think it’d be extremely beneficial to learn these terms even before you start the rotation or during the first few days, there aren’t THAT many of them anyway. I’m talking about terminology you use for the mental status exam such as: tangentiality, circumstantiality, thought blocking, etc.

– IN DELIRIUM, THE MOST IMPORTANT THING IS NOT BEING ORIENTED TO PERSON/TIME/PLACE. THAT is the super important thing for distinguishing it from psychosis.

– Child development stages may be worthwhile to review before the shelf. At least on my shelf exam, they asked about it and i totally wasn’t expecting it.

– Autonomic status is a helpful feature for distinguishing diff types of drug withdrawals. Specifically, alcohol and benzodiazapene withdrawal cause autonomic instability and can be lethal, which is much different than opiate withdrawal.

Finally, one last tip: try to enjoy it and not hate on it so much. It’s really the best time to work on your interviewing skills and empathy.

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