Physical Exam in Psychiatry and "Medical Clearance"

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]

“Now that I have full-blown, raging, impossible-to-miss Parkinson's disease, I really resent all those preceding years with the “depression” diagnosis: all those fleeting episodes of loss of balance, the tripping, falling, stumbling, spilling, dropping things; all those psychotropic drugs that never made a single bit of difference in my “mood disorder.” Dopamine is always prominently listed alongside serotonin as a brain chemical, and yet they bombarded my brain with increasingly toxic psychiatric concoctions. Never mind that I had long before lost my sense of smell. Never mind that I described “shaking inside” before the tremors were visible on the outside. Nowadays, I take a hit of dopamine and the relief is indescribable. Not only does the tremoring stop for a little while, but the onset of momentary happiness … I think it's happiness. I can't be fully certain. It was gone from my life for so long, so many years. Really, it's not at all difficult to assess.”

"Cassidy," from New York Times: When Anxiety or Depression Masks a Medical Problem

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.

Clues to “Medical” vs. Psychiatric Causes*

“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.

  • 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