Medical Clearance of the Psychiatric PatientA CME presentation by Gareth Wahl

What will we cover

Evidence for and against “medically clear”

An interesting case

Where to from here?

What is medically clear?

An ambiguous termNo medical issues (18yo with depression)

Concomitant medical issues with psychiatric issues dominating (34yo poorly controlled diabetic with depression)

Recently medically unwell but now suitable for management in a psychiatric facility (18yo post paracetamol OD now completed NAC)

What is medically clear?

The patient as currently assessed is medically suitable for management in a psychiatric facility

Less ability to manage complicated illness

Some but less access to comprehensive medical care

Not a guarantee that there is no medical illness

Not a guarantee that there is no risk of a subsequent medical illness

How do we declare a patient medically clear

Don’t forget the basic stuff

History including a basic psychiatric history

Examination including a basic mental state exam

Observations

Investigation if indicated

Investigation

Every test in the PathWest armamentarium?

Consider low/higher risk patient groups:Low: Young (18-55), no medical complaints, no new psychiatric or physical complaints, no evidence of drug/alcohol abuse

Higher: Not low.Specifically: atypical features on history, examination abnormalities, substance misuse

Low risk patients

Often need no further investigation other than thorough history, examination, observations

Is there good evidence for “routine bloods”?

There are multiple studies suggesting this is unnecessary

Janiak B, Atteberry S. Medical Clearance of the Psychiatric Patient in the Emergency Department. J Emerg Med 2012, 43(5): 866-870

Olshaker et al. Medical Clearance and Screening of Psychiatric Patients in the Emergency Department. Acad Emerg Med 1997, 4(2): 124-128

Korn et al. Medical Clearance of Psychiatric Patients without medical complaints in the Emergency Department. J Emerg Med 2000, 18(2): 173-176

Higher risk patients

FBC, UE, urine seem to be the very minimum

Consider others:LFT

Drug levels

CK/CRP/CXR

CT Head/LP/EEG

Inpatient consultation

An interesting case

25yo female BIBA with altered mental state at 9am Monday morning

Known to be zolpidem dependent, previous psychiatric admissions with depression

Last seen by mum on Saturday, seemed usual self

Sunday seemed to be sleeping most of the day

Today had bizarre behaviour – defecated on floor of bathroom, repeating “mum, mum, mum, mum”

Mum called SJA who bring patient here

HR 100, BP 130/80, SpO2 99, T 36.5

Pupils 8mm, no other neurology

Watching people move around but mute/refusing to talk

What now?

Midazolam 2.5mg

HR lowered, pupils stayed same

“Help me get off of stilnox”

10mg diazepam orally

Mum presents, and gives additional collateral historyTwo previous episodes of this both managed at Joondalup

One of these settled spontaneously after 48 hours when mum touched her on the lips

Decision to manage as zolpidem withdrawal

On review about 3 hours later patient watching people move around but mute again, shutting mouth to people trying to give her diazepam as per WC

What now?

DDx:Functional

BZD withdrawal

Functional

Plan:Admit obs as zolpidem/BZD withdrawal

I expect she will improve overnight with observation

Morning after:Similar midazolam responsive odd behaviour

CT brain

Referred to neurology

Neurology reviewed

EEG – diffuse epileptiform activity

Contents• Zolpidem• Doxylamine• Ibuprofen +/- codeine• Paracetamol +/- codeine• Promethazine• Diazepam• Pregabalin• Tramadol• Caffeine• Fexofenadine• Quetiapine• Phentermine• Doxepin• Propranolol• Fenofibrate

Z drugs

GABAergic sedative/hypnotics with minimal anxiolytic effect

Similar profile to short acting BZDs

Specific adverse effects:Complex parasomnias

Reports of hallucinations and psychosis, potentially not related to dose rate

Interactions with other psychotropics have precipitated hallucinations

Non-convulsive status epilepticus

Case reports exist of non-convulsive seizures in the context of BZD withdrawal

Case reports exist of seizures in the context of sudden zolpidem withdrawal

Where to from here?

Documenting medical clearance and what we specifically mean is important

Each institution can potentially have different requirements

For example:

Bankstown Hospital EDPHYSICAL HEALTH REVIEW FOR MENTAL HEALTH PATIENTS

Brief description of presenting problem:

Physiological Observations:Heart rate BP Temp Resp. rate O2Sats

Any acute physical health problems (including ingestion or drug side-effects) ?

Is the patient excessively drowsy or confused?(distinguish confusion from psychosis)

Can you find any evidence of physical cause for the acute presentation?

Are there any issues that the psychiatry team should follow-up?

Any questions?