How do you describle a patient with Mental Disabilities on a PCR

[White Cloud]

How would you guys Professionally describle a patient with Mental Disabilities on a PCR ? I had a patient last night with that and just could not figure it out.

Title changed to reflect content...AK

[mobey]

How bout by the diagnosis.

Cerebral palsy, FAS, Down's syndrome, Autism, Alzheimers, Traumatic brain injury, delerium, dementia, etc, etc

[White Cloud]

Many of the symptoms of cancer progression and chemotherapy can mimic Fibromyalgia once the CNS is involved. However, it would be difficult to dstinquish since if it is actually the cause of the pain. The treatment and pain management would still be focused on the cancer unless there was a need for an antiflammatory.

Some survivors of cancer do develop Fibromyalgia after they are deemed cancer free. Some believe it is from the chemical changes the body may have experienced while fighting the cancer and the chemotherapy that bring about chemical changes in the CNS and the nerve transmitters. Thus, they may have a lifetime of pain even without the cancer.

That is Unknown.

[VentMedic]

That is Unknown.

?????

[Christopher.Collins]

I second Mobey.

Now if the patient seems to be disabled but you are unable to obtain a history for any reason, just plain and simple describe how the patient is presenting to you. Of course you shouldnt say the patient is retarded or (as Ive seen on a PCR) Cou Cou for Coa Coa Puffs... but its not going to be unproffesional to say things like, pt was incoherrant in seech or pt seemed slow to respond and react to questions and various stimuli. Just remember we cant diagnos so saying something like pt demonstrates signs of retardation, though is not nessecarilly wrong nor rudley/malitiously written, how are you to know that thoes signs are secondary to retardation. I digress. If you cant get accurate history... write what you see and what happens. But dont get tunnel vision, what if they are having a TIA or CVA?

[VentMedic]

It also depends on whether you are describing a pre-existing condition or an acute situation.

Are they already taking meds for a known mental disorder? Is their mental status altered from their norm?

I find it easier to describe the altered mental status and seek out the many causes of it before writing the patient off as just having a mental disability. As well, those with existing mental disorders can also have an acute medical condition which exacerbates an alteration in their mental status. For these reasons, many psych hold faciities want medical clearance before acceptance.

[Eydawn]

If you know a diagnosis, list that. If you don't know a diagnosis, but family has told you that they are developmentally disabled or otherwise cognitively impaired, write "cognitive impairment (congenital or secondary to incident X years ago) per family."

It can be really hard to know what is baseline and what is an exacerbation on someone with a developmental disability... since you don't know them and haven't seen them before this moment.

Just do the best you can and describe things as well as you can.

Wendy

CO EMT-B

[itxtme]

Depends what you mean by "mental disibilities"

Over here we call it intellectually handicapped or IHC as grouping word; and this is not a derogatory term. That is assuming you dont mean someone with psychological problems in which case that is expressed quite differently..

[VentMedic]

Depends what you mean by "mental disibilities"

Depression is also recognized as a mental disability. There are some in EMS who have this diagnosis on their record but may be under treatment and can still function well enough on the job. However, if they are unable to work it is recognized for disability benefits by the Social Security Administration.

If you live in one of the states that has a specific law for placing someone under involuntary psych hold, your documentation will lhave to be very descriptive without prejudice. Although in most states only LEOs and mental health professionals are allowed to place someone under a psych hold.

Edited July 18, 2009 by VentMedic

[DwayneEMTP]

Without a history you simply describe your pt's behavior. Though an error I see many make is to assume that because a person has an abnormal presentation that they can not provide significant history for themselves. The vast majority of mentally 'different', (not trying to be PC, just accurate), have been fine historians for themselves. Might keep that in mind.

If I do have a history I still document behavior that leads me to believe that the history is accurate. "Pt recoils from attempts at physical contact, eye contact with medic or others in the room near completely absent, pt exhibits repetitive rocking motions/hand flapping consistent with reported history of Autism." Or the like...

It's all just what you see/hear/feel/are told...if you don't know the diagnosis, don't guess, just give enough facts to show that you attempted to do a complete and through examination to include attempts to offer appropriate emotional support.

Good question.

Dwayne