Medical Minute: Medical screening of psychiatric patients

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July 17, 2014 by dailybolusoflr

 By Amanda Crichlow, MD

We are not going to address the assessment of psychiatric risk which is a different ball game. We are going to briefly address “medical screening”

What is the purpose of medical screening?
To conduct a focused medical assessment to achieve 2 goals:

1) Determine if a medical etiology is the cause of the patient’s symptoms
2) To detect and treat any illness and/or injury in need of acute care

Why is medical screening necessary?
To identify serious medical conditions that may be masquerading as psychiatric disorders for example:

  • Delirium
  • Encephalopathy
  • Dementia
  • Traumatic brain injury
  • Cerebrovascular disease
  • Neuroendocrine abnormalities

There are high rates of active medical problems in patients presenting to ED with psychiatric complaints. However, some of these problems may be non-urgent and not need to be addressed in the ED.
The most common conditions are alcohol or drug intoxication, hypertension, tachycardia and diabetes.
There is high co-morbidity of medical illness in psychiatric patients. Some studies of psychiatric inpatients have shown that    ~ 50% of patients have serious co-morbid medical conditions.
What does it consist of?
Most articles emphasize an adequate history and physical exam (including vital signs) and cognitive examination, with a minimum of evaluating for orientation as the most important components of medical screening exam.

Studies have found that testing for orientation had a higher yield of clinically significant findings than any other screening procedure and that disorientation can be an indicator of serious underlying medical conditions in psychiatric patients.

What about labs?
Instead of routine laboratory testing, the data supports more selective testing for patients at high risk of serious medical pathology:
1) the elderly
2) preexisting medical conditions or medical complaints
3) substance abuse disorders
4) new onset of psychiatric symptoms
5) low socioeconomic status

References:
Gregory RJ, Nihalani ND, Rodriguez E. Medical screening in the emergency department for psychiatric admissions: a procedural analysis. General Hospital Psychiatry. 2004;26:405-410.

American College of Emergency Physicians Clinical Policies Subcommittee. Clinical Policy: Critical issues in the diagnosis and management of the adult psychiatric patient the emergency department. Ann Emerg Med. 2006;47:79-99.

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