Medical clearance of the psychiatric patient

1. Medical Clearance of
the Psychiatric Patient
A CME presentation by Gareth Wahl

2. What will we cover
Evidence for and against “medically clear”
An interesting case
Where to from here?

3. What is medically clear?
An ambiguous term
No medical issues (18yo with depression)
Concomitant medical issues with psychiatric
issues dominating (34yo poorly controlled diabetic
with depression)
Recently medically unwell but now suitable for
management in a psychiatric facility (18yo post
paracetamol OD now completed NAC)

4. What is medically clear?
The patient as currently assessed is medically
suitable for management in a psychiatric facility
Less ability to manage complicated illness
Some but less access to comprehensive medical
care
Not a guarantee that there is no medical illness
Not a guarantee that there is no risk of a
subsequent medical illness

5. How do we declare a
patient medically clear
Don’t forget the basic stuff
History including a basic psychiatric history
Examination including a basic mental state exam
Observations
Investigation if indicated

6. Investigation
Every test in the PathWest armamentarium?
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
Higher: Not low.
Specifically: atypical features on
history, examination abnormalities, substance
misuse

7. Low risk patients
Often need no further investigation other than
thorough history, examination, observations
Is there good evidence for “routine bloods”?
There are multiple studies suggesting this is
unnecessary
Janiak B, Atteberry S. Medical Clearance of the Psychiatric Patient in the
Emergency Department. J Emerg Med 2012, 43(5): 866-870
Olshaker et al. Medical Clearance and Screening of Psychiatric Patients in
the Emergency Department. Acad Emerg Med 1997, 4(2): 124-128
Korn et al. Medical Clearance of Psychiatric Patients without medical
complaints in the Emergency Department. J Emerg Med 2000, 18(2): 173176

8. Higher risk patients
FBC, UE, urine seem to be the very minimum
Consider others:
LFT
Drug levels
CK/CRP/CXR
CT Head/LP/EEG
Inpatient consultation

9. An interesting case

10. 25yo female BIBA with altered mental state at
9am Monday morning
Known to be zolpidem dependent, previous
psychiatric admissions with depression
Last seen by mum on Saturday, seemed usual
self
Sunday seemed to be sleeping most of the day
Today had bizarre behaviour – defecated on floor
of bathroom, repeating “mum, mum, mum, mum”
Mum called SJA who bring patient here

11. HR 100, BP 130/80, SpO2 99, T 36.5
Pupils 8mm, no other neurology
Watching people move around but mute/refusing
to talk
What now?

12. Midazolam 2.5mg
HR lowered, pupils stayed same
“Help me get off of stilnox”
10mg diazepam orally
Mum presents, and gives additional collateral history
Two previous episodes of this both managed at
Joondalup
One of these settled spontaneously after 48 hours
when mum touched her on the lips

13. Decision to manage as zolpidem withdrawal
On review about 3 hours later patient watching
people move around but mute again, shutting
mouth to people trying to give her diazepam as
per WC
What now?

14. DDx:
Functional
BZD withdrawal
Functional
Plan:
Admit obs as zolpidem/BZD withdrawal
I expect she will improve overnight with
observation

15. Morning after:
Similar midazolam responsive odd behaviour
CT brain
Referred to neurology
Neurology reviewed
EEG – diffuse epileptiform activity

16. Contents
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Zolpidem
Doxylamine
Ibuprofen +/- codeine
Paracetamol +/- codeine
Promethazine
Diazepam
Pregabalin
Tramadol
Caffeine
Fexofenadine
Quetiapine
Phentermine
Doxepin
Propranolol
Fenofibrate

19. Z drugs
GABAergic sedative/hypnotics with minimal
anxiolytic effect
Similar profile to short acting BZDs
Specific adverse effects:
Complex parasomnias
Reports of hallucinations and
psychosis, potentially not related to dose rate
Interactions with other psychotropics have
precipitated hallucinations

20. Non-convulsive status
epilepticus
Case reports exist of non-convulsive seizures in
the context of BZD withdrawal
Case reports exist of seizures in the context of
sudden zolpidem withdrawal

21. Where to from here?
Documenting medical clearance and what we
specifically mean is important
Each institution can potentially have different
requirements
For example:

22. Bankstown Hospital ED
PHYSICAL HEALTH REVIEW FOR MENTAL HEALTH PATIENTS
Brief description of presenting problem:
Physiological Observations:
Heart rate BP Temp Resp. rate O2Sats
Any acute physical health problems (including ingestion or drug sideeffects) ?
Is the patient excessively drowsy or confused?(distinguish confusion
from psychosis)
Can you find any evidence of physical cause for the acute
presentation?
Are there any issues that the psychiatry team should follow-up?

23. Any questions?