Medical clearance of psychiatric patients
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Transcript of Medical clearance of psychiatric patients
Presented by Dr Wen Guha
16/10/2014
Medically cleared or not?
Saturday night and Police brought in a 43yo male, drunk, assaulted and suicidal
PLN asks you to medically clear this patient before the psychiatry team review
Commonly used term by clinicians, but poorly defined and potentially confounding.
Means three situations: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.
What’s “medical clearance”?
2) a medical illness is known to be present but is not thought to be the primary cause of the patient’s 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.
What’s “medical clearance”?
3)the 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.
What’s “medical clearance”?
To establish if a patient’s 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.
Why psychiatrist need to medically clear a patient in ED?
Focused medical assessment: Comprehensive history including collateral
history from family/carer/case officeThorough physical examinations: vital signs,
BSL, GCSBrief and short mental status examinationSigns of intoxicationReview patient’s medications
How to medically clear a patient?
Blood tests?Several studies suggested no indication for
routine laboratory testing in ED in patients who have no self-identified medical complaints and a past psychiatric historyHigh risk groups: elderly; substance abuse; no previous psychiatry history; psych patient with new medical complaint; lower socioeconomic status
Screen tools and hospital policy
How to medically clear a patient?
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
How to medically clear a patient?Does the patient need a urine drug screen?
Alcohol level
Further investigations:CT, MRIEEG
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
What are the factors for neglecting physical exam of the psychiatry patient in ED?
45yo 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 1
Examination:Unkempt Caucasian femaleHR 80, BP 120/60, RR 16, O2sats 100% RA,
BSL 6.0mmo/L, urinalysis: NADDifficult 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 1
Is patient medically cleared?
CT head under GA: Large right side frontal infarct
Scenario 1
43yo female BIBPPMHx: depression, borderline personality
disorderHomelessBAL 0.2, crying and wants to kill her self
because had argument with ex partner.Code Black at triage: patient striped herself
and running away from EDEscorted back by security and 5mg diazepam
PO given
Scenario 2
Patient calms down after PO diazepam and becomes cooperative
Vitals: afebrile, HR 105, BP 150/90, RR 20, O2sats 96% RA, BSL 10mmol/L
Can we medically clear this patient?
Scenario 2
While 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 injury
X-ray right hand and foot:Right 4th metacarpal bone displaced neck
fractureRight cuneiform bone undisplaced fracture
Scenario 2
Plaster applied and referred patient to Ortho Clinic for follow up.
Medically cleared after the plaster and admitted to D20.
Scenario 2
“Medically 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.
Take home message
“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
Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department; From the American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department; Annals of Emergency Medicine Volume 47, no. 1 : January 2006
Evaluation of the Psychiatric Patient; Sood et al. Emerg Med Clin N Am 27 (2009) 669–683
EVIDENCE-BASED EVALUATION OF PSYCHIATRIC PATIENTS; Zun, The Journal of Emergency Medicine, Vol. 28, No. 1, pp. 35–39, 2005
Value of Mandatory Screening Studies in Emergency Department Patients Cleared for Psychiatric Admission; Parmar et al. Western Journal ofEmergency Medicine Volume XIII, NO.5 : November 2012 388-393
References