Medical clearance of psychiatric patients

1. Presented by Dr Wen Guha
16/10/2014

3. 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.

4. 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.

5. 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.

6. 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.

7. Focused medical assessment:
Comprehensive history including collateral history from
family/carer/case office
Thorough physical examinations: vital signs, BSL, GCS
Brief and short mental status examination
Signs of intoxication
Review patient’s medications

8. 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
history
High risk groups: elderly; substance abuse; no previous
psychiatry history; psych patient with new medical
complaint; lower socioeconomic status
Screen tools and hospital policy

9. 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

10. Does the patient need a urine drug screen?
Alcohol level
Further investigations:
CT, MRI
EEG

11. Patient factors
Uncooperative and difficult patient
Poor historian
Hostile and violent

12. Medical staff factors
Lack of documentation of vital signs and BSL on
observation chart
Diagnostic assumptions
Familiarity with patients who frequently present to ED:
frequent flyers

13. 45yo female from home with fulltime carer
PMHx: schizophrenia
Medications: Clozapine
Brought 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

14. Examination:
Unkempt Caucasian female
HR 80, BP 120/60, RR 16, O2sats 100% RA, BSL
6.0mmo/L, urinalysis: 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.

15. Is patient medically cleared?
CT head under GA:
Large right side frontal infarct

16. 43yo female BIBP
PMHx: depression, borderline personality disorder
Homeless
BAL 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 ED
Escorted back by security and 5mg diazepam PO given

17. 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?

18. 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 fracture
Right cuneiform bone undisplaced fracture

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

20. “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.

21. “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