A 29 year-old man is brought to the ED by police. He was found wandering on the street, predictably at 3 a.m. He is well-dressed and appropriately-groomed, slightly agitated, paranoid, apparently responding to internal stimuli, and uncooperative. He has no known history on file.
What is required for ‘medical clearance’ before referral to the psychiatry service?
Patients presenting to the ED with psychiatric complaints represent a sizeable portion of total ED visits, with some sources citing rates of 6% or greater. Though psychiatric complaints are common, there is little standardisation with respect to workup prior to referral to the psychiatric consult service. As conscientious physicians, we want to avoid missing organic illness in these patients, but also ensure appropriate use of resources, good departmental flow, and timely referral to the appropriate clinical service.
What does the literature say?
A variety of screening tools [3,4] have been tested in limited settings. None have been validated beyond the single studies that produced them. The literature is consistent, however, on a few points:
1. Of utmost importance in the evaluation of the psychiatric patient is a complete set of vital signs, including capillary glucose level. Any vitals outside normal parameters should prompt investigation,
2. An adequate history must be obtained, as much as possible. Particular attention must be paid to behavioural changes, appearance, medication use, and drug use. Collateral history can be helpful,
3. As complete a mental status exam as possible should be performed,
4. A screening neurological exam, and any other physical exams that may be necessary based on history, should be completed, including particular attention to the presence of a toxidrome.
What about lab work?
Multiple studies [1,5,6]have confirmed that screening bloodwork, including CBC, lytes, LFT’s, TSH, T4, serum drug levels, urine drug screens and urine pregnancy tests are NOT routinely indicated. If there is a specific indication in the patient history, then appropriate labwork could and should be ordered. If the patient requires chemical restraint, it is important to obtain an ECG, as many antipsychotics, including Haldol produce QT prolongation.
Aren’t there some cases where I should be more suspicious of organic etiology?
Absolutely – there are some indications that put an organic cause much higher up on our differential:
1. Abnormal vital signs,
2. Patient older than 30-40 presenting with no psychiatric history,
3. Visual or tactile hallucinations. [1,2,5,6]
Back to the Case
Vital signs obtained once the patient has calmed enough to cooperate:
HR – 87
O2 Sats: 98%
The patient denies drug use, denies medical history of any kind, and is not currently on any medications, confirmed with collateral history. His screening exam is normal, and there are no signs of toxidrome. He is remains disorganized, delusional, paranoid, and is having auditory hallucinations, but is cooperative with physical examination.
This man would be suitable to refer to psychiatry following the thorough history obtained, normal vital signs, and normal physical exam.
The Bottom Line
Vitals, a thorough history, and a good neurological exam are adequate for most patients presenting with presumed or likely isolated psychiatric complaints.
1. Janiak, B., & Atteberry, S. (2012). Medical Clearance of the Psychiatric Patient in the Emergency Department. The Journal Of Emergency Medicine, 43(5), 866-870.
2. Larkin G, Beautrais A.L. (2011). Chapter 283. Behavioral Disorders: Emergency Assessment. In Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T (Eds), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e.
3. Lukens, T., Wolf, S., Edlow, J., Shahabuddin, S., Allen, M., Currier, G., & Jagoda, A. (2006). Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Annals of Emergency Medicine, 47(1), 79-99.
4. Shah, S., Fiorito, M., & Mcnamara, R. (2012). A Screening Tool to Medically Clear Psychiatric Patients in the Emergency Department. The Journal Of Emergency Medicine, 43(5), 871-875.
5. Szpakowicz, M., & Herd, A. (2008). “Medically Cleared”: How Well are Patients with Psychiatric Presentations Examined by Emergency Physicians? The Journal Of Emergency Medicine, 35(4), 369-372.
6. Zun, L. (2005). Evidence-based evaluation of psychiatric patients. The Journal Of Emergency Medicine, 28(1), 35-39.
Reviewing with the Staff, Dr. James Huffman (@jameslhuffman)
This is a concise and accurate review of an area filled with nuance and is also one of those places where I find available literature and consulting services don’t always agree.
Part of our job is to be a “guardian of the resources” and not work things up unnecessarily. That may mean limiting work-ups before discharge or before consulting another service for admission. It can also mean having a frank discussion with said services about your interpretation of the available literature, so you can express why you don’t feel like a more exhaustive search for an organic cause for the symptoms is warranted while discerning why they are concerned (perhaps they caught something on their exam we have missed, maybe the vitals changed over time, maybe getting other investigations at a later time is systemically challenging). You’ll find that having these kinds of conversations, rather than just saying “there is no need for testing in this patient…all-stop” will not only help you reach a mutually acceptable consensus, but also build trusting and productive relationships with the non-EM physicians while building your credibility as a specialist.
The last thing that I’ll add is something I think we all start to learn through experience and that’s although it’s foolish to let anecdotes and one-off stories guide practice as a whole, sometimes that “Spidey sense” is telling you to do more of a work-up for a reason (and it seems like the medical workup of patients presenting with new possibly psychiatric issues is an area where this comes up every now and again). Do your due diligence, read and learn as much as you can, see as many patients as you can to build your “portfolio of presentations” and document your decision making processes when it comes to areas where you may be on the fence. You’ll be doing yourself and your patients a great service.