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Nina Ian John “G” Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie Ricobear

Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung Tope Bien Ag

S2 L4: LAB TEST, CLASSIFICATION, RATING SCALE, PE Pretrans

LABORATORY TEST USES


LABORATORY TEST IN PSYCHIATRY NEUROENDOCRINE TESTS
Thyroid Function Tests  Rule-out HYPOTHYROIDISM vs.
Basic Screening Tests  Test for thyroxine for competetive DEPRESSION
- Medical history binding (T4D), and Common to both are the ff:
- Routine medical laboratory tests radioimmunoassay (T4RIA) Weakness, stiffness, poor appetite,
o Complete blood count  Free T4 Index (FT4I) constipation, menstrual irregularites,
o Hematocrit and hemoglobin  T3 uptake slowed speech, apathy, impaired
o Renal, liver and thyroid function tests  T3RIA memory, and even hallucinations and
o Electrolytes  TRH stimulation test delusions
o Blood sugar Dexamethasone Suppression Test  Help confirm a diagnostic
- CT scan, MRI (DST) impression of Major Depressive
Disorder
 1 mg by mouth at 11 pm and
plasma cortisol levels are
measured at 8 am, 4 pm and 11
pm
 Plasma cortisol conc above 5mg/dL
(known as nonsuppression) are
considered abnormal
Other Endocrine Tests
Prolactin  ↑in response to the administration
of antipsychotic agents
 Elevated levels are associated with
galactorrhea, menstrual
abnormalities, alterations in libido
and bone calcium abnormalities
 Briefly rises after seizure
Catecholamines
 Serotonin Metabolite 5-  ↑in patients with carcinoid tumors
hydroxtindoleacetic acid (5-HIAA)  ↑phenothiazine medication in those
who eat foods high in serotonin
 Norepinephrine (NE), (e.g. walnuts, bananas and
metanephrine, normetanephrine, avocados)
and vanillylmandelic acid  ↓persons who are in a suicidal
depression; violence in general
 3-methoxy-4-hydroxyphenylglycol  ↑ in pheochromocytoma, which is
(MHPG) associated with anxiety, agitation,
and HPN
 NE and E is ↑ in chronic anxiety
and post traumatic stress disorder
 Depressed patients have a low
urinary NE to E ratio
 MHPG is ↓ in severe depressive
disorders
KIDNEY FUNCTION TESTS
Creatine clearance  Detects early kidney damage
BUN  ↑ in renal disease
 Monitor renal function in patients
taking lithium
LIVER FUNCTION TESTS
Total Bilirubin and Direct Bilirubin  ↑ in hepatocellular injury and
intrahepatic bile stasis w/c can
occur wi/ phenothiazine or tricyclic
medication and w/ alcohol and
other substance abuse
 Abnormal finding: liver damage or
disease can manifest with S/Sx of a
cognitive disorder, including

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disorientation and delirium - aplastic anemia, agranulocytosis, thrombocytopenia and
 Must be monitored routinely when leucopenia
using carbamazepine and
valproate Valproate
Lipids, FBS, and Glycosylated  ↑ in antipsychotic agents (FBS, - serum levels and LFTs
Hemoglobin Glycosylated Hemoglobin)
 Hypoglycemia has also been Tacrine
associated with agitation and - liver damage
anxiety baseline liver function and follow up serum transaminase every other week
 Extreme serum glucose for five months
concetration: delirium
BLOOD TESTS AND STD CLASSIFICATION IN PSYCHIATRY
Flourescent Treponemal Antibody-  Positivity is confirmed with FTA-
Absorption (FTA-ABS) ABS Nosology – classification of illnesses
(CNS) VDRL test
 For suspected neurosyphillis IMPORTANCE OF CLASSIFICATION
HIV test patients
 to distinguish one psychiatric diagnosis from another,
 HIV is test for AIDS
 so that clinicians can offer the most effective treatment
 to provide a common language among health care professionals
Tests Related to Psychotropic Drugs  to explore the still unkown causes of many mental disorders
Benzodiazepines
- No special tests 2 Most Important Psychiatric Classifications:
Antipsychotics 1. Diagnostic and Statistical Manual of Mental Disorders (DSM) –
- No special tests developed by the American Psychiatric Association in collaboration with
- Clozapine: weekly CBC for the first 6 months because the risk of other groups of mental health professionals
agranulocytosis 2. International Classification of Diseases (ICD) – developed by the World
Health Organization
Tetracyclic and Tricyclic Drugs
- Impiramine MULTIAXIAL DIAGNOSIS
- Notriptyline DSM-IV-TR is a multiaxial system that evaluates patients along several
- Desipramine variables and contains five axes. Axis I and II make up the entire
- Amitrptyline classification of mental disorder
Monoamine Oxidase Inhibitors AXIS I consists of clinical disorders and other conditions that may be a focus
- Those taking MAO inhibitors should avoid tyramine containing of clinical attention.
foods because of danger of hypertensive crisis
- MAOI can cause orthostatic hypotension as a direct drug adverse DSM-IV-TR Axis I: Clinical Disorders and other Disorders that may be a
effect Focus of Clinical Attention
 Disorders usually first diagnosed in infancy, childhood, or adolescence
Lithium (excluding mental retardation)
- Baseline thyroid function tests (hypothyroidism), electrolyte  Delirium, dementia, and amnestic and other cognitive disorders
monitoring (sodium depletion), WBC (leukocytosis), renal function  Mental disorders due to a general medical condition not elsewhere
test (renal concentration defects) and baseline ECG (ECG classified
changes)  Substance-related disorders
 Schizoprenia and other psychotic disorders
Carbamezapine  Mood disorders
 Anxiety disorders
Table 7.4-7 Laboratory Monitoring of Patients Taking Carbamazepine  Somatoform disorders
Test Frequency  Factitious disorders
1. Complete blood count (CBC) Before treatment and every 2  Dissociative disorders
weeks for the first 2 months of  Sexual and gender identity disorders
treatment; thereafter, once every 3  Eating disorders
months  Sleep disorders
2. Platelet count and reticulocyte count Before treatment and yearly  Impulse-control disorders not elsewhere classified
3. Serum electrolytes Before treatment and yearly  Adjustment disorders
4. Electrocardiogram Before treatment and yearly  Other conditions that may be a focus of clinical attention
5. Aspartate aminotransferase (SGOT), Before treatment and every month
alanine aminotransferase (SGPT), for the first 2 months of treatment; AXIS II consists of personality disorders and mental retardation. The habitual
lactate dehydrogenase (LDH) alkaline thereafter, every 3 months use of a particular defense mechanism can be indicated on Axis II.
phosphatase
6. Pregnancy test for women of Before treatment and as frequently DSM-IV-TR Axis II: Personality Disorders and Mental Retardation
childbearing age as monthly in noncompliant  Paranoid personality disorder
patients  Schizoid personality disorder
 Schizotypal personality disorder
 Antisocial personality disorder

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 Borderline personality disorder o occupational functioning
 Histrionic personality disorder o psychological functioning.
 Narcissistic personality disorder  The GAF scale, based on a continuum of mental health and mental
 Avoidant personality disorder illness, is a 100-point scale, 100 representing the highest level of
 Dependent personality disorder functioning in all areas. (Table 9-5 pg 290 Kaplan 9th ed)
 Obsessive-compulsive personality disorder  Persons who had a high level of functioning before an episode of
 Personality disorder not otherwise specified illness generally have a better prognosis than do those who had a low
 Mental retardation level of functioning.

AXIS III PSYCHIATRIC RATING SCALES

 lists any physical disorder or general medical condition that is present in  Also called rating instruments
addition to the mental disorder. The physical condition may be causative  Provide a way to quantify aspects of a patient’s psyche, behaviour, and
(e.g. kidney failure causing delirium), the result of mental disorder (e.g. relationships with individuals and society
alcohol gastritis secondary to alcohol dependence), or unrelated to the  Without rating scales, quantitative data in psychiatry are crude
mental disorder.
CHARACTERISTICS OF A RATING SCALE
DSM-IV-TR Axis III: ICD-9-CM General Medical Conditions
 Infectious and parasitic diseases (001-139)  Can be specific or comprehensive or can measure both internally
 Neoplasms (140-239) experienced variables and externally observable variables
 Endocrine, nutritional, and metabolic diseases and immunity disorders
 Specific: discrete thoughts, moods or behaviors
(240-279)
 Comprehensive: broad abstractions
 Diseases of the blood and blood-forming organs (280-289)
 Diseases of the nervous system and sense organs (320-389)
Signs and Symptoms
 Diseases of the circulatory system (390-459)
 Diseases of the respiratory system (460-519)
 Include thought disorders, mood disturbances and gross behaviors
 Diseases of the digestive system (520-579)
 Diseases of the genitourinary system (580-629)  Also cover the assessment of adverse effects from psychotherapeutic
 Complications of pregnancy, childbirth, and the puerperium (630-676) drugs
 Diseases of the skin and subcutaneous tissue (680-709)  Social adjustments and psychoanalytic concepts are also measured by
 Diseases of the musculoskeletal system and connective tissue (710-739) some rating scales, although the reliabilty and the validity of such scales
 Congenital anomalies (740-759) are lowered by the absence of agreed-on-norms, the high level of
 Certain conditions originating in the perinatal period (760-779) inference required on some items, and the lack of independence between
 Symptoms, signs, and ill-defined conditions (780-799) measures
 Injury and poisoning (800-999)
Other Characteristics
Axis IV
 Time covered
 used to code the psychosocial and environmental problems that contribute  Level of judgment required
significantly to the development or exacerbation of the current disorder.  Method of recording answers
 Evaluation of stressors is based on: clinicians’ assessment of the stress  Most reliable – require limited amount of judgment or inference on the part
that an average person with similar sociocultural values and of the rater
circumstances would experience from the psychosocial stressors
 Judgment: amount of change of stressors, degree to which the event is RATING SCALES USED IN DSM-IV-TR
desired and under the person’s control, number of stressors
GAF SCALE
 Stressors can be positive or negative
 Information on stressors may be impt in formulating a treatment plan
 Axis V in DSM-IV uses the GAF scale
DSM-IV-TR Axis IV: Psychosocial and Environmental Problems  Used to report a clinician’s judgment of a patient’s overall level of
functioning.
 Problems with primary support group
 The information is used to decide on a treatment plan and later to
 Problems related to the social environment
measure the plan’s effect
 Educational problems
 Occupational problems SOCIAL AND OCCUPATIONAL FUNCTIONING ASSESSMENT SCALE
 Housing problems
 Economic problems  This scale dan be used to track a patient’s progress in social and
 Problems with access to health care services occupational areas
 Problems related to interaction with the legal system/crime  Independent of the psychiatric diagnosis and the severity of the patient’s
 Other psychosocial and environmental problems psychological symptoms

AXIS V OTHER SCALES

 is a global assessment of functioning (GAF) scale in which clinicians judge  Global assessment of Relational Functioning (GARF)
patients’ overall levels of functioning during a particular time (e.g. at the  Defensive Functioning Scale
time of the evaluation or the patient’s highest level of functioning for at
least a few months during the past year). PHYSICAL EXAMINATION
 Three major areas of functioning
o social functioning Introduction
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- Psychiatrists should consider the medical status of patients o Breathlessness: at rest, little change with exertion,
undergoing psychiatric evaluation. fluctuate within matter of minutes, may coincide with
- It would include a thorough medical history including the review of onset of mood disorder accompanied by dizziness,
systems, physical examination and relevant laboratory diagnostic sweating, palpitations and paresthesia
tests. - Bronchial asthma: may be associated with history of extreme
dependence on mother
History of Medical Illness - Propanolol is contraindicated in patients with bronchial asthma
- Bodily diseases or dysfunctions, hospitalizations and operative
procedures, past and present medications, personal habits and Cardiovascular System
occupational history, family history of illnesses and specific - Tachycardia, palpitations and cardiac arrhythmia
complaints - Phaeochromocytoma may mimic symptoms of anxiety disorder:
rapid heart beats, tremor and pallor
Substance Abuse and Prescribed Medication Use - Tricyclic drugs are contraindicated for hypertensive patients
- Get a history of substance abuse taking guanethdine (Ismelin); tricyclic drugs remove the
- Do urine drug assay hypertensive effect of guanethidine
- Get a history of prescribed medication use - Psychological stress can trigger angina type chest pain in the
presence of normal coronary arteries.
Review of Systems - Patients taking opiods should not take monoamine oxidase
- Run down organ systems to eliminate organ causality (including inhibitors as it could cause cardiovascular collapse.
substance or medicine use)
- Rule out any organic medical basis (including substance or Gastrointestinal System
medicine use) for a psychiatric manifestation - Appetite, distress before and after meals, food preferences,
- Establish baseline for viability and safety of administering diarrhea, vomiting, constipation, laxative use and abdominal pain
psychiatric medication - Weight loss: depressive disorders, cocaine and amphetamine
- abuse
Head - Appetite loss: cocaine and amphetamine abuse
- Headache: duration, frequency, character, location and severity - Depression: may accompany weight loss caused by ulcerative
o Substance abuse: alcohol, nicotine, caffeine colitis, regional enteritis and cancer
o Vascular (migraine): stress - Weight gain: stress, atypical depression
o Temporal arteritis: unilateral, throbbing headache that - Atypical depression: hyperphagia and weight gain
may lead to blindness - Anorexia nervosa: severe weight loss in the presence of normal
o Brain tumors: headaches as a result of increase appetite
intracranial pressure; change in personality and - Avoidance of certain foods: phobic phenomenon or part of an
cognition obsessive ritual
o Subdural hematoma: in boxers may produce dementia - Bulimia nervosa: laxative use and induced vomiting
with extrapyramidal symptoms - Constipation: opiod dependence
o Subarachnoid hemorrhage: sudden, severe and - Diabetes mellitus: polyphagia, polyuria and polydipsia
associated with changes in sensorium - Lithium toxicity: polyuria, polydipsia and diarrhea
- Normal pressure hydrocephalus: head injury or encephalitis and - Enemas: paraphilic behavior
associated with dementia, shuffling gait and urinary incontinence - Anal fissures and recurrent hemorrhoids: anal penetration of
- Dizziness foreign objects
- Paget’s disease: a change in the size or shape of the head - Ingestion of foreign objects

EENT Genitourinary System


- Visual acuity, diplopia, hearing problems, tinnitus, glossitis and - Urinary frequency, nocturia, pain or burning pain on urination,
bad taste changes in the size and force of stream
- A patient taking antipsychotics who gives a history of twitching - Anticholinergic adverse effects of antipsychotic and tricyclic
about the mouth or disturbing movements of the tongue may be in drugs: urinary retention in men with prostatic hypertrophy, erectile
the early and potentially reversible stage of tardive dyskinesia. difficulty and retardation of ejaculation
- Thioridazine (Mellaril): In high doses can cause impaired vision - Thioridazine: retrograde ejaculation
- Glaucoma contraindicates drugs with anticholinergic effects - History of STD
- Aphonia: may be hysterical in nature - In some cases of AIDS, the first symptom may be gradual onset
- Late stage cocaine abuse: nasal perforations and difficulty in of mental confusion leading to dementia
breathing - Uerthral eroticism: laceration or infection
- Diplopia: multiple sclerosis - Orgasm increases PSA and gives a false positive result for
- Delusional disorder: hearing impaired persons prostatic cancer
- Bad odors: temporal lobe epilepsy
- Blue tinged vision: may occur transiently with use of sildenafil Menstrual History
(Viagra) - Age of onset of menarche and menopause, interval, regularity,
duration and amount of flow of periods, irregular bleeding ,
dysmenorrhea and abortions
Respiratory System - Amenorrhea: anorexia nervosa, women who are psychologically
- Cough, asthma, pleurisy, hemoptysis, dyspnea and orthopnea stressed
- Hyperventilation: onset at rest, sighing respirations, - Delayed periods: women afraid of getting pregnant or wanting to
apprehension, anxiety, depersonalization, palpitations, inability to be pregnant
swallow, numbness of feet and hands and carpopedal spasm - Pseudocyesis: false pregnancy with complete cessation of
- Depression: sudden onset of dyspnea and breathlessness menses

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- Perimenstrual mood changes: irritability, depression and
dysphoria
- Painful menstruation: uterine disease (myomata), psychological
conflicts

General Observation
- Visual, auditory and olfactory
- Listening is also important

Physical and Neurological Examination


- Check for physical manifestations that may be due to a
psychiatric condition (including substance or medicine abuse)
- Rule out any organic medical basis (including substance or
medicine use) for a psychiatric manifestation
- Establish viability and safety of administering psychiatric
medication

Brought to you by: Luke Psych-walker (RPE-JG)

“This is not goodbye but see you later”

-Luke

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