What is the process to medically clear a psychiatric patient?

Medical Clearance Process for Psychiatric Patients

The optimal approach to medically clearing psychiatric patients involves a focused medical assessment based on history, physical examination, and vital signs rather than routine laboratory testing for all patients. 1

Core Components of Medical Clearance

• Medical clearance aims to determine if psychiatric symptoms are caused/exacerbated by underlying medical conditions and identify medical conditions requiring acute treatment 1
• The term "medical stability" (lack of medical conditions requiring acute evaluation/treatment) is increasingly preferred over "medical clearance" 1

Step 1: Initial Assessment

• Obtain vital signs - abnormal vitals may indicate underlying medical causes of psychiatric symptoms 1
• Complete medical history with focus on:
  • New onset vs. chronic psychiatric symptoms (new symptoms warrant more thorough evaluation) 1
  • Previous psychiatric history 2
  • Current medications and substance use 1
  • Medical comorbidities 1

Step 2: Targeted Physical Examination

• Comprehensive physical exam with particular attention to neurologic, cardiac, and respiratory systems 1
• Mental status examination to assess orientation, cognition, and thought processes 1
• History and physical examination have shown sensitivities of 94% and 51% respectively for identifying medical problems in psychiatric patients 3

Step 3: Risk Stratification

Higher-risk groups requiring more extensive evaluation include:

• Elderly patients 1
• Patients with substance abuse 1
• Patients without prior psychiatric history 1
• Patients with new medical complaints 1
• Patients with abnormal vital signs 1, 4
• Patients who are disoriented, agitated, or have altered mental status 4

Step 4: Selective Laboratory Testing

• Laboratory testing should be guided by clinical findings from history and physical examination rather than using a predetermined battery of tests for all patients 1
• Routine laboratory testing has shown very low yield (1.1%) for detecting conditions that change management 4
• False positive laboratory results are 8 times more common than true positives 1
• Studies show that most abnormal results can be predicted from history and physical examination 1

Step 5: Urine Drug Testing

• Routine urine drug testing has limited utility in medical clearance 1
• Only 5% of routine toxicology screens are positive, and these rarely change management 1
• Patient self-reporting has high sensitivity (92%) and specificity (91%) for identifying substance use 3

Common Medical Conditions That Can Present as Psychiatric Disorders

Medical conditions that may masquerade as psychiatric disorders include:

• Neurologic disorders: stroke, hemorrhage, CNS tumors, trauma, infections, seizures 1
• Metabolic/endocrine disorders: electrolyte abnormalities, hypo/hyperglycemia, thyroid disorders 1
• Respiratory conditions causing hypoxia or hypercarbia 1
• Medication effects or substance intoxication/withdrawal 1

Documentation Recommendations

• Avoid using the term "medically cleared" - instead document "medically stable for psychiatric evaluation" 1
• Document thorough neurological examination (commonly deficient in medical clearance) 1
• Clearly document the rationale for any laboratory or imaging studies ordered 1

Common Pitfalls to Avoid

• Ordering routine laboratory tests for all psychiatric patients regardless of clinical presentation 1, 4
• Failing to document a thorough neurological examination 1
• Missing medical causes in younger patients (4 times higher risk of missed medical diagnosis) 1
• Overlooking high-risk groups that may benefit from more extensive testing 1
• Relying on laboratory tests rather than history and physical examination (which have higher yield - 15.6% and 14.9% respectively) 4

By following this focused approach to medical clearance, clinicians can effectively identify medical conditions that may be causing or exacerbating psychiatric symptoms while avoiding unnecessary testing and delays in psychiatric care.