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
LABORATORY TEST
LABORATORY TEST IN PSYCHIATRY NEUROENDOCRINE TESTS
Thyroid Function Tests
Basic Screening Tests  Test for thyroxine for competetive
- Medical history binding (T4D), and
- Routine medical laboratory tests radioimmunoassay (T4RIA)
o Complete blood count  Free T4 Index (FT4I)
o Hematocrit and hemoglobin  T3 uptake
o Renal, liver and thyroid function tests  T3RIA
o Electrolytes  TRH stimulation test
o Blood sugar Dexamethasone Suppression Test
- CT scan, MRI (DST)
Other Endocrine Tests
Prolactin
Catecholamines
 Serotonin Metabolite 5-
hydroxtindoleacetic acid (5-HIAA)
 Norepinephrine (NE),
metanephrine, normetanephrine,
and vanillylmandelic acid
 3-methoxy-4-hydroxyphenylglycol
(MHPG)
KIDNEY FUNCTION TESTS
Creatine clearance
BUN
LIVER FUNCTION TESTS
Total Bilirubin and Direct Bilirubin
Pretrans
USES
 Rule-out HYPOTHYROIDISM vs.
DEPRESSION
Common to both are the ff:
Weakness, stiffness, poor appetite,
constipation, menstrual irregularites,
slowed speech, apathy, impaired
memory, and even hallucinations and
delusions
 Help confirm a diagnostic
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
 ↑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
 ↑in patients with carcinoid tumors
 ↑phenothiazine medication in those
who eat foods high in serotonin
(e.g. walnuts, bananas and
avocados)
 ↓persons who are in a suicidal
depression; violence in general
 ↑ in pheochromocytoma, which is
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
 Detects early kidney damage
 ↑ in renal disease
 Monitor renal function in patients
taking lithium
 ↑ 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
undergoing psychiatric evaluation.
- It would include a thorough medical history including the review of
systems, physical examination and relevant laboratory diagnostic
tests.
History of Medical Illness
- Bodily diseases or dysfunctions, hospitalizations and operative
procedures, past and present medications, personal habits and
occupational history, family history of illnesses and specific
complaints
Substance Abuse and Prescribed Medication Use
- Get a history of substance abuse
- Do urine drug assay
- Get a history of prescribed medication use
Review of Systems
- Run down organ systems to eliminate organ causality (including
substance or medicine use)
- Rule out any organic medical basis (including substance or
medicine use) for a psychiatric manifestation
- Establish baseline for viability and safety of administering
psychiatric medication
- abuse
Head
- Headache: duration, frequency, character, location and severity
o Substance abuse: alcohol, nicotine, caffeine
o Vascular (migraine): stress
o Temporal arteritis: unilateral, throbbing headache that
may lead to blindness
o Brain tumors: headaches as a result of increase
intracranial pressure; change in personality and
cognition
o Subdural hematoma: in boxers may produce dementia
with extrapyramidal symptoms
o Subarachnoid hemorrhage: sudden, severe and
associated with changes in sensorium
- Normal pressure hydrocephalus: head injury or encephalitis and
associated with dementia, shuffling gait and urinary incontinence
- Dizziness
- Paget’s disease: a change in the size or shape of the head
EENT
- Visual acuity, diplopia, hearing problems, tinnitus, glossitis and
bad taste
- A patient taking antipsychotics who gives a history of twitching
about the mouth or disturbing movements of the tongue may be in
the early and potentially reversible stage of tardive dyskinesia.
- Thioridazine (Mellaril): In high doses can cause impaired vision
- Glaucoma contraindicates drugs with anticholinergic effects
- Aphonia: may be hysterical in nature
- Late stage cocaine abuse: nasal perforations and difficulty in
breathing
- Diplopia: multiple sclerosis
- Delusional disorder: hearing impaired persons
- Bad odors: temporal lobe epilepsy
- Blue tinged vision: may occur transiently with use of sildenafil
(Viagra)
Respiratory System
- Cough, asthma, pleurisy, hemoptysis, dyspnea and orthopnea
- Hyperventilation: onset at rest, sighing respirations,
apprehension, anxiety, depersonalization, palpitations, inability to
swallow, numbness of feet and hands and carpopedal spasm
- Depression: sudden onset of dyspnea and breathlessness
o Breathlessness: at rest, little change with exertion,
fluctuate within matter of minutes, may coincide with
onset of mood disorder accompanied by dizziness,
sweating, palpitations and paresthesia
- Bronchial asthma: may be associated with history of extreme
dependence on mother
- Propanolol is contraindicated in patients with bronchial asthma
Cardiovascular System
- Tachycardia, palpitations and cardiac arrhythmia
- Phaeochromocytoma may mimic symptoms of anxiety disorder:
rapid heart beats, tremor and pallor
- Tricyclic drugs are contraindicated for hypertensive patients
taking guanethdine (Ismelin); tricyclic drugs remove the
hypertensive effect of guanethidine
- Psychological stress can trigger angina type chest pain in the
presence of normal coronary arteries.
- Patients taking opiods should not take monoamine oxidase
inhibitors as it could cause cardiovascular collapse.
Gastrointestinal System
- Appetite, distress before and after meals, food preferences,
diarrhea, vomiting, constipation, laxative use and abdominal pain
- Weight loss: depressive disorders, cocaine and amphetamine
- Appetite loss: cocaine and amphetamine abuse
- Depression: may accompany weight loss caused by ulcerative
colitis, regional enteritis and cancer
- Weight gain: stress, atypical depression
- Atypical depression: hyperphagia and weight gain
- Anorexia nervosa: severe weight loss in the presence of normal
appetite
- Avoidance of certain foods: phobic phenomenon or part of an
obsessive ritual
- Bulimia nervosa: laxative use and induced vomiting
- Constipation: opiod dependence
- Diabetes mellitus: polyphagia, polyuria and polydipsia
- Lithium toxicity: polyuria, polydipsia and diarrhea
- Enemas: paraphilic behavior
- Anal fissures and recurrent hemorrhoids: anal penetration of
foreign objects
- Ingestion of foreign objects
Genitourinary System
- Urinary frequency, nocturia, pain or burning pain on urination,
changes in the size and force of stream
- Anticholinergic adverse effects of antipsychotic and tricyclic
drugs: urinary retention in men with prostatic hypertrophy, erectile
difficulty and retardation of ejaculation
- Thioridazine: retrograde ejaculation
- History of STD
- In some cases of AIDS, the first symptom may be gradual onset
of mental confusion leading to dementia
- Uerthral eroticism: laceration or infection
- Orgasm increases PSA and gives a false positive result for
prostatic cancer
Menstrual History
- Age of onset of menarche and menopause, interval, regularity,
duration and amount of flow of periods, irregular bleeding ,
dysmenorrhea and abortions
- Amenorrhea: anorexia nervosa, women who are psychologically
stressed
- Delayed periods: women afraid of getting pregnant or wanting to
be pregnant
- Pseudocyesis: false pregnancy with complete cessation of
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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