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Last edited on April 30, 2020

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--- teaching:3-medical-clearance-screening [on April 30, 2020]
+++ teaching:3-medical-clearance-screening [on February 20, 2023] (current)
psychdb [History]
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-====== Medical Clearance and Screening ======
+====== Physical Exam in Psychiatry and "Medical Clearance" ======
 {{INLINETOC}}
 ===== Primer =====
-<callout type="success">{{fa>arrow-circle-right?color=green}} See also the Medical Psychiatry section: **[[cl:home|]]**</callout>
+<WRAP group>
+<WRAP half column>
+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, [[:neurology|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.[([[https://pubmed.ncbi.nlm.nih.gov/28800798/|Reeves, R. R., Perry, C. L., & Burke, R. S. (2010). What does “medical clearance” for psychiatry really mean?. Journal of psychosocial nursing and mental health services, 48(8), 2-4.]])][([[https://pubmed.ncbi.nlm.nih.gov/28210358/|Anderson, E. L., Nordstrom, K., Wilson, M. P., Peltzer-Jones, J. M., Zun, L., Ng, A., & Allen, M. H. (2017). American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults part I: introduction, review and evidence-based guidelines. Western Journal of Emergency Medicine, 18(2), 235.]])][([[https://pubmed.ncbi.nlm.nih.gov/20704125/|Reeves, R. R., Perry, C. L., & Burke, R. S. (2010). What does “medical clearance” for psychiatry really mean?. Journal of psychosocial nursing and mental health services, 48(8), 2-4.]])]
+</WRAP>
+<WRAP half column>
+<callout>
+//"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."//
+\\ \\
+-- [[https://www.nytimes.com/2017/06/26/well/live/when-anxiety-or-depression-mask-a-medical-problem.html?sl_rec=mostconversions_sample_dedup&contentCollection=smarter-living&mtrref=www.psychdb.com#permid=23791259:23880188|"Cassidy,"]] from [[https://www.nytimes.com/2017/06/26/well/live/when-anxiety-or-depression-mask-a-medical-problem.html|New York Times: When Anxiety or Depression Masks a Medical Problem]]
+</callout>
+</WRAP>
+</WRAP>
-Psychiatrists play a critical role in detecting and diagnosing medical etiologies of psychiatric presentations.
+==== History ====
+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. - [[cl:0-autoimmune-encephalitis:home|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).[([[https://pubmed.ncbi.nlm.nih.gov/16387222/|Lukens, T. W., Wolf, S. J., Edlow, J. A., Shahabuddin, S., Allen, M. H., Currier, G. W., & Jagoda, A. S. (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.]])] 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.[([[https://pubmed.ncbi.nlm.nih.gov/16387222/|Lukens, T. W., Wolf, S. J., Edlow, J. A., Shahabuddin, S., Allen, M. H., Currier, G. W., & Jagoda, A. S. (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.]])]
-  * [[https://jamanetwork.com/journals/jama/article-abstract/359493?redirect=true|Massarelli, J. J. (1981). Psychiatric Presentations of Medical Illness: Somatopsychic Disorders. JAMA, 246(2), 170-170.]]
+===== Pearls =====
+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 [[geri:dementia:0-rapid-rpd|rapidly progressive dementia]])
+    * Acute or subacute onset (e.g. - sudden onset of psychosis or confusion, suggestive of [[cl:1-delirium|delirium]])
+    * Late or atypical onset psychiatric syndrome (e.g. - late onset bipolar disorder that is actually a [[geri:dementia:home|neurodegenerative disorder]] such as [[geri:dementia:frontotemporal|frontotemporal dementia]])
+    * Non-psychiatric syndromes and symptoms mistaken as psychiatric:
+      * Cortical blindness may present as “psychosis/hallucinations” (Anton’s syndrome)
+      * [[teaching:rare-unusual-syndromes|Lilliputian hallucinations]] in Charles Bonnet Syndrome may present as "visual hallucinations"
+      * [[neurology:approach-aphasia|Transcortical sensory aphasia]] may present as a "thought disorder"
+      * Alien hand syndrome (e.g. - in [[geri:dementia:corticobasal-degeneration-cbd|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 [[cognitive-testing:clock-drawing-test|abnormal clock drawing]] in first episode psychosis caused by an [[cl:0-autoimmune-encephalitis:home|autoimmune encephalitis]])
+    * [[teaching:rare-unusual-syndromes|Rare and unusual psychiatric symptoms]], such as:
+      * Capgras Syndrome
+      * Fregoli Syndrome
+      * [[psychosis:morgellons-disease-delusional-parisitosis|Delusional parasitosis (Ekbom Syndrome)]]
+  * **On physical exam and investigations**, if there are:
+    * Prominent [[neurology:neuro-exam:home|neurological exam]] findings including:
+      * [[neurology:approach-headaches|Headaches]], [[neurology:approach-seizures|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, [[neurology:neuro-exam:luria|motor sequencing difficulties such as the fist–edge–palm test]]
+      * [[cl:hyponatremia|Abnormal lab values]]
+      * Findings on [[neurology:ct-scan|neuroimaging]]
+    * Associated constitutional symptoms such as:
+      * Fever, malaise, flu-like prodrome, or other vital sign changes
+    * [[neurology:approach-seizures|Non-convulsive status epilepticus]] or absence seizures may present as “[[cl:0-catatonia|catatonia]]”)
+  * **If on [[:cognitive-testing|cognitive testing]]**, the patient presents with unusual deficits, such as:
+    * An unusual or low score on the [[cognitive-testing:moca|MoCA]]
+===== Geriatric Psychiatry =====
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">
+See main article: **[[geri:home|]]**
+</alert>
-===== Medical Screening =====
+Psychiatric presentations in late-life may be a harbinger of [[geri:dementia:home|neurodegenerative]] and neuropsychiatric disorders.
+===== Medical Psychiatry =====
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See: **[[cl:home|]]** section for a list of topics related to the interface between medicine and psychiatry, and neuropsychiatry.</alert>
+<WRAP group>
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">
+See also article: **[[cl:psychiatric-side-effects-of-medications|]]**
+</alert>
+<WRAP half column>
+  * [[https://jamanetwork.com/journals/jama/article-abstract/359493?redirect=true|Massarelli, J. J. (1981). Psychiatric Presentations of Medical Illness: Somatopsychic Disorders. JAMA, 246(2), 170-170.]]
   * [[https://www.ncbi.nlm.nih.gov/pubmed/23456449|Castro, J., & Billick, S. (2013). Psychiatric presentations/manifestations of medical illnesses. Psychiatric Quarterly, 84(3), 351-362.]]
+  * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6684120/|Esang, M., Goldstein, S., & Dhami, R. (2019). The Role of Physical Examinations in Psychiatry as Illustrated in a Case of Neuroleptic Malignant Syndrome Versus Viral Encephalitis: A Case Report and Literature Review. Cureus, 11(6).]]
+  * [[https://www.psychiatrictimes.com/view/should-psychiatrists-perform-physical-examinations|PsychiatricTimes: Should Psychiatrists Perform Physical Examinations?]]
+  * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220088/|Yao, J., Lv, D., & Chen, W. (2018). Multiple Myeloma, Misdiagnosed As Somatic Symptom Disorder: A Case Report. Frontiers in psychiatry, 9, 557.]]
+</WRAP>
+<WRAP half column>
+<panel type="info" title="Clues to “Medical” vs. Psychiatric Causes*" subtitle="" no-body="true" footer="* = This is a rough, holistic guide, and should not replace a thorough focus physical/neurological exam, and proper investigations!">
+<mobiletable 1>
+^                               ^ "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                       |
+</mobiletable>
+</panel>
+</WRAP>
+</WRAP>
 ===== Neuroimaging =====
-Although most guidelines recommend patients with psychiatric symptoms and no neurological symptoms to not have neuroimaging,[([[https://www.ncbi.nlm.nih.gov/pubmed/18462577|Albon, E., Tsourapas, A., Frew, E., Davenport, C., Oyebode, F., Bayliss, S., ... & Meads, C. (2008). Structural neuroimaging in psychosis: a systematic review and economic evaluation.]])] 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.
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See main section: **[[:neurology|]]**</alert>
+Although most guidelines recommend that patients with psychiatric symptoms and no neurological symptoms to not have neuroimaging,[([[https://www.ncbi.nlm.nih.gov/pubmed/18462577|Albon, E., Tsourapas, A., Frew, E., Davenport, C., Oyebode, F., Bayliss, S., ... & Meads, C. (2008). Structural neuroimaging in psychosis: a systematic review and economic evaluation.]])] 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.
+==== CNS Lesions ====
   * [[https://www.ncbi.nlm.nih.gov/pubmed/16400253|Moise, D., & Madhusoodanan, S. (2006). Psychiatric symptoms associated with brain tumors: a clinical enigma. CNS spectrums, 11(1), 28-31.]]
-  * [[https://www.ncbi.nlm.nih.gov/pubmed/19037181|Bunevicius, A., Deltuva, V. P., Deltuviene, D., Tamasauskas, A., & Bunevicius, R. (2008). Brain lesions manifesting as psychiatric disorders: eight cases. CNS spectrums, 13(11), 950-958.]]
+  * [[https://www.ncbi.nlm.nih.gov/pubmed/19037181|Bunevicius, A. et al. (2008). Brain lesions manifesting as psychiatric disorders: eight cases. CNS spectrums, 13(11), 950-958.]]
-  * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314926/|Yakhmi, S., Sidhu, B. S., Kaur, J., & Kaur, A. (2015). Diagnosis of frontal meningioma presenting with psychiatric symptoms. Indian journal of psychiatry, 57(1), 91.]]
+  * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314926/|Yakhmi, S. et al. (2015). Diagnosis of frontal meningioma presenting with psychiatric symptoms. Indian journal of psychiatry, 57(1), 91.]]
-  * [[http://www.gjpsy.uni-goettingen.de/gjp-article-sarkheil.pdf|Sarkheil, P., Werner, J. C., Mull, M., Schneider, F., & Neuner, I. (2010). Depressive episode induced by frontal tumor culminating in suicidal ideation. Ger J Psychiatry, 13, 150-3.]]
+  * [[http://www.gjpsy.uni-goettingen.de/gjp-article-sarkheil.pdf|Sarkheil, P. et al. (2010). Depressive episode induced by frontal tumor culminating in suicidal ideation. Ger J Psychiatry, 13, 150-3.]]
-  * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287917/|Arifin, M. Z., Yudoyono, F., Setiawan, C., Sidabutar, R., Sutiono, A. B., & Faried, A. (2014). Comprehensive management of frontal and cerebellar tumor patients with personality changes and suicidal tendencies. Surgical neurology international, 5.]]
+  * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287917/|Arifin, M. Z. et al. (2014). Comprehensive management of frontal and cerebellar tumor patients with personality changes and suicidal tendencies. Surgical neurology international, 5.]]
   * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1989489/|Hunter, R., Blackwood, W., & Bull, J. (1968). Three cases of frontal meningiomas presenting psychiatrically. Br Med J, 3(5609), 9-16.]]
+===== Neuropsychiatry =====
   * [[http://www.jneuropsychiatry.org/peer-review/selected-neuropsychiatric-masquerades-a-brief-review.html|Madhusoodanan, S., Soltan, A., & Wilson, S. Y. (2016). Selected neuropsychiatric masquerades: a brief review. Neuropsychiatry, 6(2), 47-54.]]
+  * [[https://jnnp.bmj.com/content/76/suppl_1/i31|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.]]
 ===== Psychosis =====
-==== NMDAR Encephalitis =====
+==== Autoimmune Encephalitis =====
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See main article: **[[cl:0-autoimmune-encephalitis:home]]**</alert>
 ==== Rheumatological/Autoimmune ====
   * 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.
@@ Line 35: / Line 119: @@
   * Fibromyalgia symptoms
 ===== Anxiety =====
-===== Depression =====
+  * [[https://www.psychiatrictimes.com/view/managing-anxiety-medically-ill|Psychiatric Times: Managing Anxiety in the Medically Ill]]
+  * [[https://www.psychiatrictimes.com/view/7-medical-illnesses-may-present-anxiety|Psychiatric Times: 7 Medical Illnesses That May Present as Anxiety]]
-<imgcaption fig1|>{{:teaching:core:medical-vs-psych.png?nolink&400|Clues to medical versus psychiatric causes of behavioural symptoms}}</imgcaption>
 ===== Resources =====
+  * [[https://emergencymedicinecases.com/medical-clearance-psychiatric-patient/|EM Cases: Episode 85 – Medical Clearance of the Psychiatric Patient]]
-<callout>
-//"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."//
-\\
--- [[https://www.nytimes.com/2017/06/26/well/live/when-anxiety-or-depression-mask-a-medical-problem.html?sl_rec=mostconversions_sample_dedup&contentCollection=smarter-living&mtrref=www.psychdb.com#permid=23791259:23880188|New York Times Reader Comment ("Cassidy")]], from [[https://www.nytimes.com/2017/06/26/well/live/when-anxiety-or-depression-mask-a-medical-problem.html?sl_rec=mostconversions_sample_dedup&contentCollection=smarter-living|NYT: When Anxiety or Depression Masks a Medical Problem]]
-</callout>
 {{tag>ax-dx}}