What up-to-date (UTD) investigations should be done for a patient with cardiac, respiratory, and psychiatric symptoms?

Up-to-Date Investigations for Patients with Cardiac, Respiratory, and Psychiatric Symptoms

The most appropriate investigations for patients with cardiac, respiratory, and psychiatric symptoms should include a focused medical assessment based on history, physical examination, and vital signs, followed by selective laboratory and diagnostic testing guided by clinical findings rather than routine testing for all patients. 1

Initial Assessment

• Obtain complete vital signs - abnormal vitals may indicate underlying medical causes of psychiatric symptoms 1
• Comprehensive physical examination with particular attention to neurological, cardiac, and respiratory systems 1
• Mental status examination to assess orientation, cognition, and thought processes 1
• Detailed medical history focusing on:
  • New onset versus chronic psychiatric symptoms 1
  • Current medications and substance use 1
  • Medical comorbidities 1
  • Family history of cardiac disease or sudden cardiac death 2

Cardiac Investigations

• Electrocardiogram (ECG) should be performed in all patients with cardiac and psychiatric symptoms to rule out underlying heart disease 2
• Transthoracic echocardiography should be performed in all patients with suspected cardiac involvement 2
• For patients with multiple cardiovascular risk factors or age >50 years, a cardiopulmonary exercise test should be performed to uncover asymptomatic ischemic heart disease 2
• If coronary disease is suspected in high-risk patients, coronary angiography should be considered 2
• Holter monitoring or prolonged ECG monitoring may be indicated in patients with palpitations associated with syncope 2

Respiratory Investigations

• Lung function tests and chest X-ray are recommended for patients with respiratory symptoms 2
• If hepatopulmonary syndrome (HPS) or portopulmonary hypertension (PPHTN) are suspected, calculate the alveolar-arterial oxygen gradient and perform contrast echocardiography 2
• For patients with dyspnea, wheezing, or coughing, consider pulmonary function testing 2

Psychiatric Evaluation

• Psychiatric assessment is recommended in patients with frequent recurrent symptoms who have multiple somatic complaints 2
• Consider evaluation for neurally mediated syncope (tilt testing and carotid massage) in patients with recurrent or severe syncope without evidence of cardiac disease 2
• For patients with suspected psychogenic non-epileptic seizures (PNES), consider EEG monitoring 2

Risk Stratification for More Extensive Testing

• Higher-risk groups requiring more extensive evaluation include: 2, 1
  • Elderly patients
  • Patients with substance abuse
  • Patients without prior psychiatric history
  • Patients with new medical complaints
  • Patients of lower socioeconomic status

Laboratory Testing Approach

• Laboratory testing should be guided by clinical findings rather than using a predetermined battery of tests 2, 1
• False positive laboratory results are 8 times more common than true positives in routine testing 1
• Consider targeted testing based on specific symptoms and risk factors 2
• Basic laboratory tests are only indicated if symptoms may be due to loss of circulating volume or if a metabolic cause is suspected 2

Common Pitfalls to Avoid

• Ordering routine laboratory tests for all psychiatric patients regardless of clinical presentation 1
• Failing to document a thorough neurological examination 1
• Missing medical causes in younger patients 1
• Overlooking the high prevalence of psychiatric comorbidity in cardiac patients (44-75% in some studies) 3, 4
• Failing to recognize that some patients may have both true medical conditions and psychiatric symptoms concurrently 2

Documentation

• Avoid using the term "medically cleared" - instead document "medically stable for psychiatric evaluation" 1
• Document thorough neurological examination and clearly state the rationale for any laboratory or imaging studies ordered 1
• Document the presence of any cardiac, respiratory, or psychiatric symptoms that may require follow-up 2