PART 3 / CH 16
Medical Clearance
Marion Eakin
Medical clearance is done by APS with consultation as needed from the medical/surgical teams. Goal is to state confidently that the patient has no acute medical issues and is stable for transfer to an inpatient psychiatric unit. This is not the time to work up chronic complaints.
Key elements include:
1. PMHx and ROS:
a. which organ systems to focus on in the physical exam
b. any history of head trauma, seizure or DT’s
c. lab tests to order
d. need for further work-up, such as EKG or imaging.
2. Screening physical exam (adults):
| System | Assess for |
|---|---|
| VS | evidence of intoxication/withdrawal |
| Skin | track marks, rash reactions to meds, signs of self-mutilation |
| HEENT | dilated/constricted pupils, nystagmus |
| Neck | stiffness, thyromegaly/nodules |
| Chest | reactive airway flare, hyperventilation |
| Neuro | ataxia, tremor, focal deficits |
· MGH pediatrics residents expect to be called for exams on patients up to age 18. Use your own comfort level for ages 13-18.
· Labs are rarely required for child psychiatric admissions; one exception is bHCG for all females of reproductive age. Other indications: overdose, substance abuse history, comorbid medical issues, valproate/ Li levels
3. Routine admission labs:
| Lab | Notes |
|---|---|
| CBC | with differential if on clozapine |
| Chem 7 | |
| b-HCG | ALL women of reproductive age |
| Urine Tox | good for recent cocaine, marijuana, amphet. |
| Serum Tox | basic panels for most psych admits, complete screen for history of substance abuse or in case of suspected overdose |
4. Additional labs as needed:
| Test | Indication |
|---|---|
| Breath-alyzer | useful for rapid initial assessment of EtOH level and repeat EtOH levels prior to transfer |
| LFTs | on/starting VPA, long hx of EtOH use, hx of hepatitis or in case of suspected OD |
| TSH | depressed or jittery, suggestive signs/symptoms of hypo or hyperthyroid |
| Levels | Valproate, Lithium, Tegretol, Dilantin; Digoxin (ideally at trough = 12 hours after last dose) |
| PT/INR | patient on coumadin |
| U/A | pre-ECT or if elderly and confused |
| EKG | history of cardiac disease; irregular pulse, suspected OD, cocaine intoxication; pre-ECT; male >40 or female >55 and are on/ will start psychotropic or cardiac meds |
| CXR | pre-ECT or if elderly and confused |
| head CT | suspected stroke, bleed, mass |
5. Labs for particular circumstances
| Diagnosis | Labs |
|---|---|
| pre-ECT | CBC, chem7, EKG, CXR, U/A |
| overdose | Triage to medical/ED service! CBC, chem20 (including LFT’s), EKG Full serum tox screens Call to request drug levels where applicable. |
| EtOH | LFT, amylase (if abdominal pain present) |
| new onset psychosis | as needed to r/o delirium (see Delirium) |