On Monday we learned that the concept of "medically clearing" a psychiatric patient isn't a process derived from consensus. Please refer to my previous post for an introduction. We learned that oftentimes we are asked to acquire lab work or toxicology screenings on these patients when in fact to rule out acute medical issues, it is often more sensitive to use a thorough history or conversation with a patient.
Today I want to go over some techniques to rule out acute medical issues in patients with psychiatric complaints.
Generally, the approach to patients with behavioral complaints should be similar to those with medical conditions. We should obtain a thorough history, consider the ABCs, a focused physical exam, and selected testing. Although a detailed mental exam is not necessary for every patient with a behavioral complaint, in determining if a patient has an altered level of awareness, a useful tool can be The Quick Confusion Scale
The Quick Confusion Scale
What month is it?
Repeat phrase and remember it: “John Brown, 42 Market Street, New York”
About what time is it?
Count backward from 20 to 1
Say the months in reverse
Repeat the memory phrase
Although this scale can be useful, it should also be noted that an experienced clinician can determine if a patient has diminished awareness by subjectively assessing orientation, memory and judgement. Some other things to remember are to check a BGM and to remember that visual hallucinations are usually secondary to organic illness while auditory hallucinations are secondary to psychiatric illnesses.
This is a useful algorithm from EMCases to determine who needs workup-
When a patient needs ancillary lab workup or a head CT:
NO WORKUP NEEDED
Pitfalls in the medical assessment of psychiatric patients
Incomplete history, including failure to obtain ancillary information.
Cursory physical without full vitals, mental status exam, brief neurologic exam and assessment for toxidromes.
Premature closure of a psychiatric diagnosis.
Indiscriminate lab and imaging testing.
Main Takeaways
Approach undifferentiated behavioral patients in a similar manner you would a patient with a routine medical complaint. Focus on the ABCs, obtain a thorough history, a focused physical exam, and a complete review of systems. Avoid premature closure in psychiatric diagnoses.
Keep in mind the patients that are at high risk for having a medical illness as the reason for their behavioral presentation. This is including but not limited to patients with no prior presentation to the ED, patients with no prior psych diagnosis, and the elderly.
Avoid routine testing as a screening method. Approach workup in these patients as you would any medical patient, pertinent to the existing complaint and after a thorough history and physical.
Hope this post gives some clarity in this topic. In order to provide an efficient and appropriate disposition for our patients, please consider these steps when evaluating a patient for medical clearance.
Thank you for your time and have a wonderful day
Mak Sarich MD
EM PGY-3
References
https://emergencymedicinecases.com/medical-clearance-psychiatric-patient/