Physical Exam in Psychiatry and "Medical Clearance"

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:

• On history, a neurological contribution or underlying medical cause should be considered when there is a:
  • Rapidly progressive course that is unlike typical psychiatric presentations (e.g. - a rapidly progressive dementia)
  • Acute or subacute onset (e.g. - sudden onset of psychosis or confusion, suggestive of delirium)
  • Late or atypical onset psychiatric syndrome (e.g. - late onset bipolar disorder that is actually a neurodegenerative disorder such as frontotemporal dementia)
  • Non-psychiatric syndromes and symptoms mistaken as psychiatric:
    • Cortical blindness may present as “psychosis/hallucinations” (Anton’s syndrome)
    • Lilliputian hallucinations in Charles Bonnet Syndrome may present as “visual hallucinations”
    • Transcortical sensory aphasia may present as a “thought disorder”
    • Alien hand syndrome (e.g. - in corticobasal degeneration) mistaken for passivity or “responding to internal stimuli” or “command hallucinations”
• On clinical progression, a neurological contribution or underlying medical cause should be considered if there is:
  • A poor response or worsening with psychiatric treatment
  • Atypical presentation of psychiatric illness that do not seem consistent with its typical presentation (e.g. - aphasia, severe cognitive impairment, or an abnormal clock drawing in first episode psychosis caused by an autoimmune encephalitis)
  • Rare and unusual psychiatric symptoms, such as:
    • Capgras Syndrome
    • Fregoli Syndrome
    • Delusional parasitosis (Ekbom Syndrome)
• On physical exam and investigations, if there are:
  • Prominent neurological exam findings including:
    • Headaches, seizures, clonus, hyperreflexia, tremor, chorea, dysautonomia, gait abnormalities (ataxia), primitive reflexes (Glabellar tap, snout, grasp, palmomental), upper motor neuron signs such as the Babinski, sensory extinction and graphaesthesia, motor sequencing difficulties such as the fist–edge–palm test
    • Abnormal lab values
    • Findings on neuroimaging
  • Associated constitutional symptoms such as:
    • Fever, malaise, flu-like prodrome, or other vital sign changes
  • Non-convulsive status epilepticus or absence seizures may present as “catatonia”)
• If on cognitive testing, the patient presents with unusual deficits, such as:
  • An unusual or low score on the MoCA

Psychiatric presentations in late-life may be a harbinger of neurodegenerative and neuropsychiatric disorders.

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.

• Moise, D., & Madhusoodanan, S. (2006). Psychiatric symptoms associated with brain tumors: a clinical enigma. CNS spectrums, 11(1), 28-31.
• Bunevicius, A. et al. (2008). Brain lesions manifesting as psychiatric disorders: eight cases. CNS spectrums, 13(11), 950-958.
• Yakhmi, S. et al. (2015). Diagnosis of frontal meningioma presenting with psychiatric symptoms. Indian journal of psychiatry, 57(1), 91.
• Sarkheil, P. et al. (2010). Depressive episode induced by frontal tumor culminating in suicidal ideation. Ger J Psychiatry, 13, 150-3.
• Arifin, M. Z. et al. (2014). Comprehensive management of frontal and cerebellar tumor patients with personality changes and suicidal tendencies. Surgical neurology international, 5.
• Hunter, R., Blackwood, W., & Bull, J. (1968). Three cases of frontal meningiomas presenting psychiatrically. Br Med J, 3(5609), 9-16.

• Madhusoodanan, S., Soltan, A., & Wilson, S. Y. (2016). Selected neuropsychiatric masquerades: a brief review. Neuropsychiatry, 6(2), 47-54.
• Butler, C., & Zeman, A. Z. J. (2005). Neurological syndromes which can be mistaken for psychiatric conditions. Journal of Neurology, Neurosurgery & Psychiatry, 76(suppl 1), i31-i38.

• Ask about rashes, skin changes other than acne, ulcers, joint pain, joint swelling, hair loss, dry eyes, dry mouth, muscle pain, and cardiovascular, GI, or respiratory symptoms.
• Other phenomena such as Raynaud syndrome should also be asked on history
• Personal or family history of autoimmune disease
• Unusual rashes
• Abnormal weight loss
• Oral ulcers, uveitis, iritis, fevers, alopecia, arthritis or other joint pain concerns
• Fibromyalgia symptoms

• Psychiatric Times: Managing Anxiety in the Medically Ill
• Psychiatric Times: 7 Medical Illnesses That May Present as Anxiety

• EM Cases: Episode 85 – Medical Clearance of the Psychiatric Patient