Original Contributions
Unrecognized medical emergencies admitted to psychiatric units,☆☆,,★★,

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Abstract

Alteration of mental status secondary to medical illness may occasionally be incorrectly attributed to a psychiatric problem. The cases of 64 patients with unrecognized medical emergencies inappropriately admitted to psychiatric units from emergency departments were reviewed to determine the cause of the misdiagnoses. Medical diagnoses most often missed included severe intoxication with alcohol or other illicit substance (34.4%), drug or alcohol withdrawal or delirium tremens (12.5%), and prescription drug overdose (12.5%). In none of the cases (0%) was an appropriate mental status examination performed. Other common causes of misdiagnosis included inadequate physical examination (43.8%), failure to obtain indicated laboratory studies (34.4%), and failure to obtain available history (34.4%). A systematic approach is required for patients with altered mental status, including those with psychiatric presentations. (Am J Emerg Med 2000;18:390-393. Copyright © 2000 by W.B. Saunders Company)

Section snippets

Methods

The records of 64 patients with alteration of mental status secondary to unrecognized medical emergencies who were inappropriately admitted from emergency departments to psychiatric units were reviewed. In these cases the patients had a serious underlying medical problem causing changes in mentation, but the changes were erroneously assumed to be attributable to a psychiatric problem. For the purposes of this study “medical emergency” was defined as the patient having significant enough medical

Results

The missed medical diagnoses in the 64 patients erroneously admitted from emergency departments to psychiatric units are shown in Table 1.

. Missed Medical Diagnoses Inappropriately Admitted to Psychiatric Units (N = 64)

Severe intoxication with alcohol or other illicit substance22 (34.4%)
Drug or alcohol withdrawal or delirium tremens8 (12.5%)
Prescription drug overdose8 (12.5%)
Uremic encephalopathy4 (6.3%)
Hepatic encephalopathy2 (3.1%)
Diabetic ketoacidosis2 (3.1%)
Hypoglycemia1 (1.6%)
Wernicke's

Discussion

These findings demonstrate that unless a practitioner is systematic in his evaluation, he may incorrectly attribute altered mentation to a psychiatric problem when it is in fact caused by an underlying medical problem. Terms used to describe the state of acutely altered mental functioning include delirium, organic brain syndrome, and encephalopathy. The term “delirium” will be used in this article. Delirium is characterized by disturbance of consciousness, impaired attention, and changes in

Conclusions

Failing to perform an adequate mental status examination is a major error leading to misdiagnosis or lack of recognition of delirium. Physicians sometimes conclude too quickly that a psychiatric patient's alteration of mental status is due to an exacerbation of his or her psychiatric problem. Of the 64 cases reviewed, 43 (67.1%) carried a previous diagnoses of mental illness, suggesting that some psychiatric patients are given a less detailed evaluation than are other patients, possibly because

References (13)

  • MF Folstein et al.

    The “Mini-Mental State”: A practical method for grading the cognitive state of patients for the clinician

    J Psychiatric Res

    (1975)
  • DA Rund et al.

    Emergency Psychiatry

    (1983)
  • RR Reeves et al.

    Recognizing delirium in patients with psychiatric symptoms

    South Med J

    (1994)
  • RR Reeves et al.

    Psychiatric presentations of medical problems

    Fed Pract

    (1998)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (1994)
  • ED Caine et al.

    Delirium, dementia, and amnestic and other cognitive disorders and mental disorders due to a general medical condition

There are more references available in the full text version of this article.

Cited by (0)

Supported in part by the VISN 16 Mental Illness Research, Education, and Clinical Center, Little Rock, AR.

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Returned October 1, 1999.

Address reprint requests to Roy R. Reeves, DO, PhD, VA Medical Center-Psychiatry (116A), 1500 E. Woodrow Wilson, Jackson, MS 39216.

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Am J Emerg Med 2000;18:390-393.

0735-6757/00/1804-0007$10.00/0

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