1. Medical Clearance in the Psychiatric Patient Michael Carlisle, DO University Hospitals Geauga Medical Center

2. Emergency Department  When a patient with an acute psychiatric illness presents to the Emergency Department, the Emergency Physician is responsible to “medically clear” the patient  This process must take place prior to admission or transfer of that patient to a psychiatric facility  The process of medical clearance is variable and may change with different practitioners and referral institutions

3. The purpose of medical clearance is two-fold  First, the Emergency Physician must determine whether the patient has a medical condition that is causing or exacerbating the abnormal behavior or thought processes  Second, the Emergency Physician must identify incidental conditions that may require treatment  A standard medical clearance protocol may facilitate this process

4. The medical clearance process is the first step of evaluation and treatment…  The psychiatric patient in the Emergency Department will need:  1. A medical work-up  AND  A. An inpatient medical evaluation  OR  B. to be psychiatrically hospitalized

5. The medical work-up  There are many medical conditions that may cause a patient to have abnormal behavior or thought processes  Conditions such as Delirium; Dementia; Hypoglycemia; drug and alcohol intoxication or withdrawal; infection; and central nervous system disease, such as Normal Pressure Hydrocephalus and Complex Migraine are part of a large differential for a medical etiology  Delirium and Dementia are both states of altered mental status that have very different characteristics  Delirium: an acute, transient disorder with impairment of attention and cognition  Dementia: in contrast, an insidious disorder that is characterized by a loss of mental capacity evidenced by failing cognitive abilities and behavioral problems

6. Are psychiatric symptoms due to a psychiatric or medical process?  Use clues in the history and physical exam  Dubin and colleagues identified four criteria that can be used to identify a medical cause of psychiatric symptoms:  Age of patient over 40 years of age without prior psychiatric history  Abnormal vital signs  Recent memory loss  Clouded consciousness

7. Clues to medical vs. psychiatric cause of behavioral symptoms Organic clues  40 years of age  Sudden onset (hours to days)  Fluctuating course  Disorientation  Decreased consciousness  Visual hallucinations  No psychiatric history  Emotional lability Functional clues  13-40 years of age  Gradual onset (weeks to months)  Continuous course  Scattered thoughts  Awake and alert  Auditory hallucinations  Psychiatric history  Flat affect

8. Clues to medical vs. psychiatric cause of behavioral symptoms Organic clues  Abnormal vitals/physical exam findings (eg, nystagmus, ataxia, diaphoresis, etc)  History of substance abuse or toxins Functional clues  Normal physical examination findings

9. Up to the Emergency Physician to identify and treat any incidental…  Or co-existing medical problems of a patient with abnormal behavior  Very important for the accepting psychiatric facility  If a co-existing condition such as well controlled diabetes requires insulin administration and glucose checks the accepting facility must have those capabilities  Important for the Emergency Physician to identify co-existing and/or incidental medical conditions that will need to be addressed in the near future  The accepting facilities ability to perform things such as laboratory draws, maintenance of urinary catheters, oxygen administration, and fracture care needs to be verified prior to transfer

10. Medical Clearance, or Medical Stability  Determined by taking a thorough history as well as performing a good physical and mental status and laboratory testing  The key reasons for performing a medical work-up is to make certain the patient is ultimately sent to the right place  A patient with psychiatric symptoms caused by a medical condition should not be sent to a psychiatric facility  The history of a patient with psychiatric symptoms should be taken like any other emergency department patient, paying special attention to the psychiatric symptoms  However….

11. Psychiatric patients  Many are unable or unwilling to give any history other than the details of their chief complaint  History should then be obtained from family, friends, police or emergency medical service  History should include psychiatric history and medical symptoms (ie, neurologic, cardiovascular, and endocrine) to ascertain if there could be an organic cause for psychiatric symptoms  Questions about prescription drugs, nonprescription drugs, and alcohol abuse must be asked as intoxication or acute withdrawal may contribute to psychiatric complaints

12. Physical exam for the psychiatric patient  Should be as thorough as any other emergency department patient  A complete physical includes vital signs, general appearance, and a head-to- toe exam including a neurologic exam  Neurologic exam should include cranial nerves, gait, strength, as so forth  It is a well-known fact that patients presenting with mainly psychiatric symptoms do not receive as thorough of an exam as other emergency department patients (1)  After the physical exam, a mental status exam should be documented  There is no consensus on which type of mental status exam should be performed on the patient with psychiatric symptoms

13. Testing  The last component of the medical clearance process, and likely the most debatable, is the testing  Some say with a good history and physical, the laboratory testing can be minimal  Others say laboratory testing is always required because the history and physical are not always thorough

14. Emergency Physicians vs. Psychiatrists  Ordering practice very different  Emergency physicians generally ordered fewer required tests than psychiatrists…contributing to a lower cost  Non-psychiatrists are too quick in saying a patient is medically clear because of their discomfort with psychiatric patients (2)  On the other side, psychiatrists require more testing to assure the patients are medically stable prior to acceptance to hide their discomfort with the medical assessment  The drive for ordering tests, whether medically indicated or not, come in part for the accepting psychiatric facility

15. Many psychiatric facilities have a list of laboratory tests that must be complete…  Before even considering transfer  Given this, the emergency physician is forced to order many laboratory tests which de-emphasize the history, physical, and mental status exam  Emergency physicians and psychiatrists do order similar laboratory tests  Surveys showed both groups ordered similar routine tests, which included a complete blood count, alcohol level, and urine drug screen  Both emergency physicians and psychiatrists order urine drug screens and alcohol levels as the most frequent required tests  If a patient is awake, alert, and cooperative, routine drug testing does not change emergency department management  The American Psychiatric Association (APA) encourages psychiatrists to request or initiate further general medical testing that emerge from the psychiatric evaluation

16. Patient Case  50 year old Caucasian woman presents to Emergency Room with psychiatric symptoms of “repeating the same day,” memory loss, and hearing voices that the food was poisoned

17. Patient Case  What labs/tests would you order?  New onset psychosis or known history of psychosis?

18. Patient Case  She has history Hypothyroidism but stopped her thyroid hormone replacement therapy about a year ago  TSH 129.11  T4 0.9 (4.7-13.3)

19. Patient Case  Urinalysis  Large (3+) Leukocyte Esterase  Positive Nitrite  >100 WBC/hpf

20. Patient Case  Sodium  134  Potassium  3.3  Creatinine  2.00

21. Patient Case  Head CT Scan  No acute intracranial abnormality

22. Patient Case  UTI treated with Nitrofurantoin  Hypothyroidism treated with Levthyroxine 75 mcg daily  Psychosis treated with Aripiprozole 30 mg daily  Depression treated with Citalprom 40 mg daily and Mirtazapine 15 mg HS

23. Patient Case  The patient spent 5 days on medicine service  She spent 10 days on psychiatric unit  She was discharged to an assisted living home

24. Commonly ordered laboratory tests  Comprehensive metabolic panel  Electrolytes  Antipsychotics and water intoxication can cause Hyponatremia  Hypokalemia can predispose to prolonged QTc interval which antipsychotics can worsen  New onset Diabetes Mellitus with second generation atypical antipsychotics  Renal function  Lithium can worsen, Rhabdomyolysis can worsen  Hepatic function  Most psychotropic medications are metabolized hepatically, comorbid alcohol use

25. Commonly ordered laboratory tests  Complete Blood Count  Infection, anemia’s, side effects of medications  Lithium can cause elevation in WBC counts  Valproic acid can lower platelets  Chronic alcohol use can lower platelets  Microcytic and Macrocytic Anemias (Vitamin B12 and Folate)

26. Urine toxicology and blood alcohol level  Patients are not always forthcoming  Benzodiazepine and alcohol withdrawal can be life threatening  Referall for chemical dependency treatment can be influenced by urine toxicology

27. Urine or serum pregnancy  Avoiding known teratogenic drugs in pregnancy

28. New onset psychosis  Head CT Scan without contrast  To rule out space occupying lesion  VDRL or RPR  To rule out infecton  HIV antibody screen

29. TSH  Identify Hyper or Hypothyroid states as can appear like psychiatric symptoms

30. Urinalysis  Essential in evaluating Delirium in elderly due to the likelihood of a Urinary Tract Infection

31. References  1. Dubin WR, Weiss KJ, Zeccardi JA. Organic brain syndrome. The psychiatric imposter. JAMA. 1981;249(1): 60-62.  1. Emembolu FN, Zun LS. Medical Clearance in the Emergency Department: Is Testing Indicated? Primary Psychiatry. 2010;17(6):29-34.  2. Weissberg MP. Emergency room medical clearance: an educational problem. Am J Psychiatry. 1979;136(6):787-790.