The Physical Exam (and its associated investigations) is an important part of a psychiatrist's assessment – a psychiatrist is a physician after all! Thus psychiatrists must play some role in assessing or diagnosing both psychiatric, neurological, and medical causes of psychiatric symptoms. Unfortunately, for many psychiatrists, the physical exam and investigations has often been deferred to other specialists or family doctors. Thus, rather than sharpening the physical exam and general medical knowledge for psychiatric practice, it has become lost in routine practice for many. What may end up happening is the psychiatrist requesting for “medical clearance” of a patient, which is actually a clinically useless term that is poorly defined.[1][2][3]
The historic goal of “medical clearance” was to categorize patients as having organic versus functional causes for their symptoms. The reality is that it is impossible to rule out all medical conditions that could mimic psychiatric illness within the course of a single visit, especially in an emergency setting, and there are increasingly medical conditions that bridge the gap between both medical and psychiatric domains (e.g. - autoimmune encephalitis). Thus, the term “medically clear” is inaccurate and misleading. The term focused medical assessment (FMA) is the preferred term and is endorsed by the American Association of Emergency Physicians (ACEP).[4] A FMA thus is meant to determine with reasonable certainty whether the patient's symptoms could be caused by a medical condition that, unless identified, could place the patient at risk if admitted to a psychiatric ward rather than a medical ward.[5]
There are many things to consider when wanting to “medically clear” a patient, including:
Psychiatric presentations in late-life may be a harbinger of neurodegenerative and neuropsychiatric disorders.
“Organic” | Psychiatric | |
---|---|---|
Age | <12 or >40 | 13-40 |
Onset | hours to days | Weeks to months |
Course | Fluctuating | Continuous |
Orientation | Disorientation | Scattered/tangential thoughts |
Level of consciousness (LOC) | Decreased LOC | Alert |
Hallucinations | Visual | Auditory |
Psychiatric History | None | May or may not be related |
Physical Exam | Abnormal vitals, neurological findings | “Normal” physical exam |
Substance Use History | Possible | Possible |
Although most guidelines recommend that patients with psychiatric symptoms and no neurological symptoms to not have neuroimaging,[6] there are many case reports of neurologic lesions masquerading as psychiatric illness in the absence of neurological symptoms. This is especially true in those with atypical psychiatric symptoms.