Utility of Investigations, History, and Physical Examination in "Medical Clearance" of Psychiatric Patients: A Meta-Analysis

OBJECTIVE

Few reviews and no meta-analyses have explored the utility of investigations, such as laboratory tests, among patients presenting with psychiatric symptoms, and none has explored the yield of history and physical examination. A meta-analysis of studies exploring the utility of "medical clearance" among adult psychiatric patients was conducted.

METHODS

PubMed, PsycInfo, and Web of Science were systematically searched from inception until February 15, 2021. Primary outcome was detection by investigations (e.g., bloodwork and imaging), history, or physical examination of an illness that caused or aggravated psychiatric symptoms or was comorbid and that resulted in change in the patient's diagnosis or management ("yield"). A mixed-effects meta-analysis with inverse-variance weighting was used to pool results.

RESULTS

Twenty-five cross-sectional studies were included. Pooled yield of investigations was 1.1% (95% confidence interval [CI]=0.5%-2.2%), although yield was relatively higher among disoriented, agitated, or older patients. Yield was higher in the inpatient setting, compared with the emergency room, with similar results by approach (protocolized versus nonprotocolized). Compared with investigations, yield of history and physical examination was higher (15.6%, 95% CI=9.1%-25.6%, and 14.9%, 95% CI=8.1%-25.9%, respectively), with nonsignificant differences by evaluator (psychiatrist versus nonpsychiatrist) for physical examination.

CONCLUSIONS

Investigations were of relatively low yield, especially when weighed against cost and potential harm, and they should not be routinely conducted for patients presenting with primarily psychiatric complaints, although certain subgroups may benefit. History and physical examination, by contrast, should be undertaken for all patients, ideally with participation of the consulting psychiatrist.

Focused Medical Assessment of Pediatric Behavioral Emergencies

There is no uniformly accepted standard of care for medical clearance of pediatric patients with psychiatric complaints. Emerging data argue for a thorough history and physical examination and against routine laboratory testing. The differential diagnosis of patients presenting with psychiatric health complaints is extensive and includes both medical and psychiatric disorders. Providers should remain mindful of anchoring or diagnosis momentum bias when caring for these patients, especially patients with a psychiatric history.

The potential dangers of neck manipulation & risk for dissection and devastating stroke: An illustrative case & review of the literature

Chiropractic cervical manipulation is a common practice utilized around the world. Most patients are never cleared medically for manipulation, which can be devastating for those few who are at increased risk for dissections. The high velocity thrust used in cervical manipulation can produce significant strain on carotid and vertebral vessels. Once a dissection has occurred, the risk of thrombus formation, ischemic stroke, paralysis, and even death is drastically increased. In this case report, we highlight a case of a 32-year-old woman who underwent chiropractic manipulation and had vertebral artery dissection with subsequent brainstem infarct. She quickly deteriorated and passed away shortly after arrival to the hospital. Although rare, one in 48 chiropractors have experienced such an event. We utilize this case to highlight the risk associated with cervical manipulation and urge open dialogue between chiropractors and physicians. Receiving medical clearance prior to cervical manipulation in potential at risk patients would drastically reduce morbidity and mortality.

Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 1

Patients presenting to the emergency department with mental illness or behavioral complaints merit workup for underlying physical conditions that can trigger, mimic, or worsen psychiatric symptoms. However, interdisciplinary consensus on medical clearance is lacking, leading to wide variations in quality of care and, quite often, poor medical care. Psychiatry and emergency medicine specialty guidelines support a tailored, customized approach. This article summarizes best-practice approaches to the medical clearance of patients with psychiatric illness, tips on history taking, system reviews, clinical or physical examination, and common pitfalls in the medical clearance process.

The impact of CT head scans on ED management and length of stay in bizarre behavior patients

METHODS

A 5-year retrospective chart review was conducted at 3 EDs. Inclusion criteria were patients ≥18years old triaged as "mental health - bizarre behavior" (deviation from normal cognitive behaviour with no obvious cause) with a CT head scan ordered in the ED. Exclusion criteria were focal neurologic deficits on exam, alternative medical etiology (i.e. delirium, trauma) and/or pre-existing CNS disease. Clinical, demographic and administrative data were extracted with 10% of charts independently reviewed by an Emergency Physician for inter-rater reliability.

RESULTS

266 cases met study criteria. Population demographics: 49% percent female, average age 51years old, 28% homeless, 58% arrived by police or ambulance. CT head results: 1 (0.4%) case with possible acute findings, 105 (39%) with incidental findings (i.e. cerebral atrophy) that did not impact clinical management. Average time to physician assessment was 1:48 (hour:min) (sd 1:11), time to CT completion was 5:05 (sd 7:28) and an average delay of 3:17 awaiting results. Subgroup analysis revealed a net increase in ED length of stay (ED LOS) of 5:02 from obtaining neuroimaging. 85% of patients were referred to a consultant, 92% were to psychiatry.

CONCLUSIONS

CT head results prolonged ED LOS, delayed patient disposition and did not change the patient's clinical management. A prospective trial for ordering CT head scans in these patients is warranted.

What is the impact of obtaining medical clearance to participate in a randomised controlled trial examining a physical activity intervention on the socio-demographic and risk factor profiles of included participants?

BACKGROUND

Requiring individuals to obtain medical clearance to exercise prior to participation in physical activity interventions is common. The impact this has on the socio-demographic characteristic profiles of participants who end up participating in the intervention is not clear.

METHODS

As part of the multi-component eligibility screening for inclusion in a three-arm randomised controlled trial examining the efficacy of a web-based physical activity intervention, individuals interested in participating were required to complete the Physical Activity Readiness Questionnaire (PAR-Q). The PAR-Q identified individuals as having lower or higher risk. Higher-risk individuals were required to obtain medical exercise clearance prior to enrolment. Comparisons of the socio-demographic characteristics of the lower- and higher-risk individuals were performed using t tests and chi-square tests (p = 0.05).

RESULTS

A total of 1244 individuals expressed interest in participating, and 432 were enrolled without needing to undergo further screening. Of the 251 individuals required to obtain medical clearance, 148 received clearance, 15 did not receive clearance and 88 did not return any form of clearance. A total of 105 individuals were enrolled after obtaining clearance, and the most frequent reason for being required to seek clearance was for using blood pressure/heart condition medication. Higher-risk individuals were significantly older, had a higher body mass index and engaged in more sedentary behaviour than lower-risk individuals.

CONCLUSIONS

Use of more inclusive participant screening protocols that maintain high levels of participant safety are encouraged. Allowing individuals to obtain medical clearance to participate can result in including a more diverse population likely to benefit most from participation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( ACTRN12611000157976 ). Registered on 9 February 2011.

Spinal surgery: Who is in charge anyway?

BACKGROUND

More and more, no one seems to be in charge of taking care of patients with spinal disease both before and after spine surgery. Yet, as spine surgeons, we should not have to direct basic medical clearance prior to surgery, or direct basic medical postoperative care.

METHODS

As we as spine surgeons did not complete medical residencies, why are we now being asked to take care of all postoperative issues in our patients undergoing spine surgery. As "captains of the ship," we are increasingly managing hypertension, diabetes, deep venous thrombosis/pulmonary embolism, and other basic medical issues.

RESULTS

Although our medical colleagues perform the preoperative clearance, too frequently they are not involved in the patients' follow-up treatment. Often, our medical colleagues are nowhere to be found after surgery for any of the postoperative problems; therefore, "tag" we are it. Nevertheless, this should not be the case.

CONCLUSIONS

So I ask again, who's in charge? Are we as spine surgeons now supposed to become the patients' primary care physicians, their pulmonologists, cardiologists, pain management specialists, much less their psychiatrists. Unfortunately, if we don't do this, no one else appears to be willing to step.

Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies

Patients presenting with behavior or psychiatric complaints may have an underlying medical disorder causing or worsening their symptoms. Misdiagnosing a medical illness as psychiatric can lead to increased morbidity and mortality. A thorough history and physical examination, including mental status, are important to identify these causes and guide further testing. Laboratory and ancillary testing should be guided by what is indicated based on clinical assessment. Certain patient populations and signs and symptoms have a higher association with organic causes of behavioral complaints. Many medical problems can present with or exacerbate psychiatric symptoms, and a thorough medical assessment is imperative.