Medical Clearance For A psychiatric patient

Done By:Al Yaqdhan Al Atbi, MDEM residentMedical Clearance For A psychiatric patient

OUTLINEWhats medical clearance?Importance of the TopicWhy psychiatrist need to medically clear a patient in ED?How to medically clear a patient?What are the factors for neglecting physical exam of the psychiatry patient in ED?Clinical ScenariosHome Message

Scenario45yo female from home with fulltime carerPMHx: schizophreniaMedications: ClozapineBrought in by sister, patient deteriorates over last 2 weeks, difficult to engage in a conversation, strange behaviours (wandering in house, urination on the floor), refuses her medications sometimes in last 2 weeks. Denies recent infective illness/fall/head injury

ScenarioExamination:Unkempt femaleHR 80, BP 120/60, RR 16, O2sats 100% RA, BSL 6.0mmo/Lurinalysis: NAD

Difficult to perform physical examination :uncooperative, but she has equal power on all limbs, normal gait, nil facial droop.

Can not engage patient in a conversation. She does not follow any verbal commands and speaks words with no meaning.Is patient medically cleared?

Whats medical clearance?Commonly used term by clinicians, but poorly defined and potentially confounding.

Medical clearance is defined as within reasonable medical certainty, there is no contributory medical condition causing the psychiatric complaints presented, there is no concern at present for a medical emergency, and the patient is medical stable for transfer to the intended facility.

Medical clearance is a term commonly used for the initial medical evaluation or focused medical assessment performed in the ED prior to transfer to a psychiatric facility. L Joseph et al

Medical clearance is not a term to represent the absence of medical issues, but rather theabsence of medical instability or a medical condition causing or contributing to the psychiatric presentation.http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/

http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/6

Whats medical clearance?Means three situations:There is no medical illness present A medical illness is known to be present but is not thought to be the primary cause of the patients symptoms;The medical illness that was present no longer needs medical treatment.

Situation 1: There is no medical illness present

Example: 23yo Schizoaffective disorder female, did not take medications for last 2 weeks. Brought in by family because of worsening auditory hallucination symptoms. Denies illicit drug or alcohol use.

Whats medical clearance?Situation 2:a medical illness is known to be present but is not thought to be the primary cause of the patients symptoms;

Example: 65yo male has Bipolar disorder and T2DM. Feels more depressed for last 2 months and wants to be reviewed by psychiatry team. Has BSL 18mmol/L for last a few weeks, nil signs of infection.

Whats medical clearance?Situation 3the medical illness that was present no longer needs medical treatment.

Example: 43yo male has chronic suicidal ideation and worsening over last 2 days. PMHx Cauda equina syndrome, wheel chair bound due to previous back injury.

Importance of the TopicIn US:rate of ED mental healthrelated visits increased 38%Mental health and/or substance abuse accounts for about one of every eight ED visits.

In Oman Do We Have A Psychiatric ED??The vast majority of acute behavioral problems are assessed and treated in general hospital EDs

Why psychiatrist need to medically clear a patient in ED?To establish if a patients symptoms are caused or exacerbated by a medical illness: i.e delirium, absence seizure, hyperthyroidism.

To assess and treat any medical situation that needs acute intervention.

To determine if the patient is intoxicated , thereby preventing an accurate psychiatric evaluation.

In some hospitals/facilities, the ED examination may be the only medical assessment that patient receives during the entire hospitalisation.

How to medically clear a patient?

MENTAL STATUS EXAMINATIONA mental status examination Help identify delirium, medical disorders, and psychiatric disordersIdentify patients who are dangerous to themselves or othersHelp assess patient disposition

Mental status exam

http://www.therapistaid.com/therapy-worksheet/mental-status-exam

InvestigationsBlood tests?There are multiple studies suggesting this is unnecessary

Consider low/higher risk patient groups:Low: Young (18-55), no medical complaints, no new psychiatric or physical complaints, no evidence of drug/alcohol abuse

High risk groups: elderly; substance abuse; no previous psychiatry history; psych patient with new medical complaint; lower socioeconomic status

Screen tools and hospital policy

Low risk patientsOften need no further investigation other than thorough history, examination, observations.

Is there good evidence for routine bloods?There are multiple studies suggesting this is unnecessaryJaniak B, Atteberry S. Medical Clearance of the Psychiatric Patient in the Emergency Department. J Emerg Med 2012, 43(5): 866-870Olshaker et al. Medical Clearance and Screening of Psychiatric Patients in the Emergency Department. Acad Emerg Med 1997, 4(2): 124-128Korn et al. Medical Clearance of Psychiatric Patients without medical complaints in the Emergency Department. J Emerg Med 2000, 18(2): 173-176

http://www.ncbi.nlm.nih.gov/pubmed/2011790420

Higher risk patientsFBC, UE, urine seem to be the very minimumConsider others:LFTDrug levelsCK/CRP/CXRCT Head/LP/EEGInpatient consultation

How to medically clear a patient?Does the patient need a urine drug screen?

Alcohol level

Further investigations:CT, MRIEEG

How to medically clear a patient?

A SCREENING TOOL TO MEDICALLY CLEAR PSYCHIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT; Shah et al. The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 871 875, 2012

What are the factors for neglecting physical exam of the psychiatry patient in ED?Patient factorsUncooperative and difficult patientPoor historianHostile and violent

What are the factors for neglecting physical exam of the psychiatry patient in ED?Medical staff factorsLack of documentation of vital signs and BSL on observation chartDiagnostic assumptionsFamiliarity with patients who frequently present to ED: frequent flyers

Scenario 145yo female from home with fulltime carerPMHx: schizophreniaMedications: ClozapineBrought in by sister, patient deteriorates over last 2 weeks, difficult to engage in a conversation, strange behaviours (wandering in house, urination on the floor), refuses her medications sometimes in last 2 weeks. Denies recent infective illness/fall/head injury

Scenario 1Examination:Unkempt femaleHR 80, BP 120/60, RR 16, O2sats 100% RA, BSL 6.0mmo/Lurinalysis: NAD

Difficult to perform physical examination :uncooperative, but she has equal power on all limbs, normal gait, nil facial droop.

Can not engage patient in a conversation. She does not follow any verbal commands and speaks words with no meaning.

Scenario 1Is patient medically cleared?

CT head under GA: Large right side frontal infarct

Scenario 243yo femalePMHx: depression, borderline personality disorderHomelesscrying and wants to kill her self because had argument with ex partner.At triage: patient striped herself and running away from EDEscorted back by security and 5mg diazepam PO given

Scenario 2Patient calms down after PO diazepam and becomes cooperativeVitals: afebrile, HR 105, BP 150/90, RR 20, O2sats 96% RA, BSL 10mmol/LCan we medically clear this patient?

Scenario 2While she was telling you how horrible her ex partner treat her, you saw she has a red patch on her right hand and the hand looks a bit swollen. What happened?She said she was drunk and angry 3 days ago, punched a wall. Also said she hurt her right foot as well, but she was too drunk, cannot recall the injuryX-ray right hand and foot:Right 4th metacarpal bone displaced neck fractureRight cuneiform bone undisplaced fracture

Scenario 2Plaster applied and referred patient to Ortho Clinic for follow up.Medically cleared after the plaster and admitted to D20.

Take home messageMedically clear is a poor definition, better handover with a detailed discharge summary.

Focused medical examination and thorough history is important when reviewing patients presenting to ED with mental health issues.

Beware of frequent flyers. They might actually present with a genuine medical issue.

ReferencesTintinalli's Emergency medicine. SECTION 24: Psychosocial Disorders. CHAPTER 286: Mental Health Disorders: ED Evaluation and Disposition

MEDICALLY CLEARED: HOW WELL ARE PATIENTS WITH PSYCHIATRIC PRESENTATIONS EXAMINED BY EMERGENCY PHYSICIANS? Szpakowicz et al. The Journal of Emergency Medicine, Vol. 35, No. 4, pp. 369 372, 2008

MEDICAL CLEARANCE OF THE PSYCHIATRIC PATIENT IN THE EMERGENCY DEPARTMENT ; Janiak et al. The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 866 870, 2012

A SCREENING TOOL TO MEDICALLY CLEAR PSYCHIATRIC PATIENTS IN THE EMERGENCY DEPARTMENT; Shah et al. The Journal of Emergency Medicine, Vol. 43, No. 5, pp. 871 875, 2012

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