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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 

Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland

Monday, November 27, 2017

Patients requiring "medical clearance"

Majority of the disease burden that we see in Emergency Departments includes Geriatric pathologies and Psychiatric issues. Whenever Psychiatry evaluates any patient, they always ask for "medical clearance" and want us to mention this specifically on the chart. I often come across patients who visit Emergency Department more than I do as an A&E physician. Regardless, they go through this process of "medical clearance" every time. 

Frequently, it gets difficult to document "medically cleared". For instance, when psych patients have slightly high blood glucose but do not need anything besides some IV fluids or they might come up with a BP of 180/90 due to agitation. Additionally, getting a precise drug history can be a challenge in this subgroup of patients as they frequently take several medications for underlying chronic illnesses. It can be problematic if we document medically cleared on the chart and I believe "No acute medical concerns at this point or Fit for Psychiatric assessment" is a better way to clear these patients. Medical evaluation is used to determine whether the patient has a medical condition that is causing or exacerbating the psychiatric illness. 

At any cost we do not want to miss an underlying medical pathology. Things that we need to look for to r/o organic cause of Psych symptoms:
  • ABCs as always
  • Vital Signs (PR, BP, RR, Temp, SpO2, Glucose) - Do not ignore abnormal VS
  • Pupils and Skin exam (pick cues for toxidromes)
  • Focused History (Next of Kin/Paramedics) and Physical exam
  • Focus on underlying Psych issues (Drugs/Alcohol, Sexual, Suicidal, Homicidal, Social aspects)
  • Medications and Co-Morbidities 
  • Document Mental Exam - Appearance, Behaviour, Cognition, Speech, Mood, Insight, Thoughts, Hallucinations

Most of them do not require blood tests. Bloods are done in those with:
1. New-onset psychiatric complaints
2. Abnormal vital signs
3. Elderly
4. Known co-morbid conditions. 

Even Urine Drug Sceen is not  required routinely for all. Most of them will tell you what drugs they have recently taken. Also remember, UDS may have false positive and negatives which can be misleading.

Signs suggesting underlying medical pathology are:
  • Abnormal Vital Signs
  • Clouded Consciousness 
  • Age >40 with no previous Psych issues
  • Focal deficits on exam
  • Abnormal Physical examination 
  • Visual Hallucinations 

Visual hallucinations can also occur in psychiatric illnesses but assume medical pathology until proven otherwise

Take Home:

  • Spend more time on history and exam rather than doing bloods on everyone
  • Do not ignore abnormal Vital Signs
  • Look at issues that often co-exist with Psych illnesses - Drugs/Alcohol, Sexual, Suicidal, Homicidal, Social aspects

Further Reading:

  • Korn CS, Currier GW, Henderson SO: Medical clearance of psychiatric patients without medical complaints in the emergency department. J Emerg Med 18: 173, 2000. 
  • American Psychiatric Association: Practice guideline for psychiatric evaluation of adults. Am J Psychiatry 152: 63, 1995. 
  • Korn CS, Currier GW, Henderson SO: “Medical clearance” of psychiatric patients with- out medical complaints in the emergency department. J Emerg Med 18: 173, 2000. 
  • Olshaker JS, Browne B, Jerrard DA, Prendergast H, Stair TO: Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med 4: 124, 1997. 
  • Broderick KB, Lerner B, Mccourt JD, Fraser E, Salerno K: Emergency physician practices and requirements regarding the medical screening examination of psychiatric patients. Acad Emerg Med 9: 88, 2002. 

Posted by:

     Lakshay Chanana
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine


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