Physical Exam on Psych Patients

[psych.MD]

Is a complete physical exam required upon admission of every psych patient?

For example, if the patient is acutely psychotic obviously don't you wait for awhile.

Also, there have been many patients that I will safe talking with across the table/desk but would feel somewhat uneasy about being close enough to ausculate their lungs if you know what I mean.

You never really know when the patient will get aggressive either so how do you ever trust being that close to patients that you just admitted?

Do you have a security guard in with you on any patient that you feel uneasy with?

Do you always interview patients in a common area?

Thanks!

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[whopper]

Is a complete physical exam required upon admission of every psych patient?

Yep unless your state has different guidelines than my state.

You're a doc. Any new patient you see that comes into your care, you're supposed to do a physical exam. Yeah I know some people don't think psychiatrists are medical doctors but we are.

Speaking from experience, a lot of idiots I've seen--attendings included wouldn't do a physical exam and just write a normal exam down. Don't do that.

Every few months you do get a patient with a serious medical problem, and if you were stupid enough to not follow standard of care and not do the PE you'll miss it.

Plenty of times ER docs and floor docs medically clear a patient who isn't really cleared and they report a normal PE. You will learn that a lot of them are just playing "turfing" with you and the patient isn't truly cleared. If you faked a PE and wrote a normal exam and that patient later goes south, you're screwed.

There's also things you may learn from the PE that are relevant psychiatrically. Some cutters cut specific patterns, cut deep to the point where its a surgical emergency but they were idiotically medically cleared, IVDA's somtimes have S. aurueus infections etc.

Had a case where a fellow resident just wrote down normal PEs but didn't really do them. He eventually got a patient with several 2nd degree burns on her body and the idiot ER doctor medically cleared her. He continued the error and just wrote a normal PE without examining her. She was in the psyche unit for 3 days before the attending found out. The resident got off easy. If I were the attending, I would've written the incident down into that resident's permanent record.

I've had situations where the patient was dangerous and PEs jeoparized safety. If the patient is openly agitated, you can document that you didn't perform an exam because the patient was openly hostile. However from my experience, pretty much all patients that are hostile will get taken down with haldol and then you can do a PE.

The patient can also refuse the exam. If they refuse it, you document the pt refused and you don't have to do one. However if you don't do one, you must offer one everyday the pt is in the hospital and if they eventually agree to one, you then do the PE and document the results. Otherwise up until the day of discharge you document that the pt refused but was offered one every day of the hospital stay.

I pretty much do any PEs with a 3rd party (e.g. a nurse) as long as the patient is a female.

 

[atsai3]

Is a complete physical exam required upon admission of every psych patient?

Yes.

For example, if the patient is acutely psychotic obviously don't you wait for awhile.

You can always write "physical exam deferred due to agitation". However, if you defer exam, it is just that. You still have to document a full physical exam later on. And if you are doing a shift in the psych ER or something like that, this is a task that needs to be signed out to the incoming resident.

Do you have a security guard in with you on any patient that you feel uneasy with?

If you are in the ER, you can always ask a security guard to accompany you or stand outside the door. If you are on the wards, you can ask one of the nurses to accompany you. Often they are much more perceptive than you (residents, students) and can gently suggest that you back off if they think the patient is getting revved up. They can also run out into the hall to call a code green if for some reason the patient lunges and you get tangled up.

That being said, I can't say that's ever happened to me.

Do you always interview patients in a common area?

No. If your patient isn't acutely agitated, you are probably discussing very sensitive matters with your patient. After months and months of triaging, many residents start to take some subject matter for granted (eg., screening for SI & HI), but all it takes is for one patient to break down in tears when you ask them about suicide to remind you that these are not "normal" topics of everyday conversation. Try to give your patients some privacy.

Physical exams should never be done in the common areas. It is, however, appropriate and often advisable to ask for a chaperone of the same sex as the patient.

Cheers
-AT.

 

[Hurricane]

There is no shame in asking for a chaperone if a patient makes you nervous. The other day I asked a nurse to chaperone when I had to do an exam on a patient who was hypersexual, antisocial, and making inappropriate comments about what he was going to "do" to me in the exam room. You bet I got a chaperone.

And I agree with above about making sure to do a real physical exam, regardless of whether the ER "medically cleared" the patient. There are some ER docs that don't want to touch psych patients, and turf them over to you as quickly as they can, and stuff gets missed in their haste. If the patient is too agitated to tolerate a physical, document that, and do it as soon as you can. And never EVER write that you did something if you didn't really do it.

I personally like doing physicals because it gives me some extra time to chat with the patient in a non-psychish manner, and oftentimes forgotten medical history pops up.

However, the one thing about psychiatrists doing physical exams that I don't like is the rectal. Here at the VA, we are required to offer it for all men over 40, then document if the patient declines, which happens most of the time, but not always. I know we're real doctors and all, but I think that having your psychiatrist stick their finger up your butt possibly crosses some boundaries and isn't the best thing for a therapeutic relationship. And they don't require that we give women pelvics (nor should they) so why must we subject our male patients to this invasive exam?

 

[whopper]

There are some ER docs that don't want to touch psych patients, and turf them over to you as quickly as they can, and stuff gets missed in their haste

It surprises me how much this happens and it happens supposedly in almost every institution. You figure that an ER doc writing down a perfectly normal physical exam without even examining the patient would have some action taken against him/her....nope, not from what I'm seeing and this is at several hospitals.

I understand how sometimes some medical sx and problems don't become apparent until after the pt gets shipped to psyche, but in the case I mentioned above, where a pt had 2nd degree burns--that's just ridiculous.

I wonder what can be done by us psychiatrists, since from what I'm told this is a nationwide problem at several institutions.

 

[Anasazi23]

However, the one thing about psychiatrists doing physical exams that I don't like is the rectal. Here at the VA, we are required to offer it for all men over 40, then document if the patient declines, which happens most of the time, but not always. I know we're real doctors and all, but I think that having your psychiatrist stick their finger up your butt possibly crosses some boundaries and isn't the best thing for a therapeutic relationship. And they don't require that we give women pelvics (nor should they) so why must we subject our male patients to this invasive exam?

You're not supposed to, and it's a flawed, scared policy. There is such a thing as "not clinically indicated" given the nature of the relationship and strong liklihood that any therapeutic alliance will be distorted due to the DRE.

 

[watermen]

What a joke. Complete physical exam in psychiatry. I highly doubt those psychiatrists still remember how to do physical exam. In my psychiatry rotation, I have NEVER seen those psychiatry residents and attendings do a complete physical exam. My impression is that they just don't know how to do it...They only know how to give antipsychotic or anti-depression drugs...they only know how to talk...no action.

 

[Hurricane]

You're not supposed to, and it's a flawed, scared policy. There is such a thing as "not clinically indicated" given the nature of the relationship and strong liklihood that any therapeutic alliance will be distorted due to the DRE.

Is it written somewhere that we're not supposed to? I'd love to show it to the guy in charge of us at the VA. He seems to think we have to because of some lawsuit where a woman's family sued her family doctor for not explaining the risks of her repeated refusals to get a PAP smear. Which has nothing to do with 40 y/o men on an inpt psych ward, but whatever. And even more illogically, he's not after us to do pelvic exams on the female patients.

In response, the residents have perfected the art of asking in such a way as to practically guarantee that the patient declines. Not in a mean way though. Basically we strongly urge them to get checked by their PCP and slip the offer in (hopefully) under the radar

 

[watermen]

In response, the residents have perfected the art of asking in such a way as to practically guarantee that the patient declines. Not in a mean way though. Basically we strongly urge them to get checked by their PCP and slip the offer in (hopefully) under the radar

Agree...in my psychiatry rotation...I saw those psychiatry residents or attendings ask in such a perfect way that the patient natural response is to decline....

 

[Psychintern2006]

Doing a good physical exam is important for inpatient admissions. Most of the patients have been on the streets shooting drugs, or overdosed or been kicked and punched or have long standing medical histories. Definitely to document fresh cuts/wounds/injuries/tattoos/scars. We are not doing genital/rectal/breast exams- till now I have not found any patient with an indication to be done on emergent basis at time of admission.

It is totally acceptable to defer the Physical Exam (and also the Interview) in acutely Psychotic patient.

I have heard and agree with 'polluting alliance for therapy" for doing Physical exam esp in bipolar-revolving door patients.

I think it is acceptable to interview in common area esp if you know patient is acutely psychotic and you are definitely going to admit the patient. And the purpose of the admission is just to verify that the criterias for hospitalization are being met.

Detailed interview can be done up on the floors. It is not the best thing to put yourself in danger. Again it depends how busy is the common area.

After reading the tragedy with Dr Fenton, I will definintely discourage all peers and colleagues to jeopardize their safety.

 

[whopper]

In my psychiatry rotation, I have NEVER seen those psychiatry residents and attendings do a complete physical exam. My impression is that they just don't know how to do it...They only know how to give antipsychotic or anti-depression drugs...they only know how to talk...no action.

That's kinda sad.

But it seems there's several psychiatrists who fit this description.

What's really sad is when a psychiatrist doesn't even look at the labs. The patient's depression could be due to hypothyroidism but the psychiatrist never found out because they never even checked the labs.

With all this brouhaha with us psychiatrists getting mad about psychologists getting the power to prescribe, you'd figure that psychiatrists would then try to exploit and advertise why we're different than psychologists and how our medical training gives us a leg up when it comes to the medical stuff. Nope--at least from several psychiatrists I've seen.

Is it written somewhere that we're not supposed to?

As far as I know, and someone correct me if I'm wrong, psychiatrists are still practicing doctors and still must practice the standard of care, and that includes doing things like physical exams when patients come under your care.

As for the primary care stuff, such as screening them from to the typical preventative medicine stuff such as rectal exams, colonscopies etc, as far as I know and someone correct me if I'm wrong, we need to make it clear that we are not their primary care doctor and they need to get one if they don't have one. This should to some degree shield you if that pt gets some problem that was nonpsychiatric while under your care.

However if the pt is an inpt and you're their doctor, then while they're in the hospital you are their primary doc. Now long term, nonacute things don't have to be handled right then and there, and if the pt will have a discharge within a few days to weeks you can just tell them to follow up with their primary care docs when they get discharged. You can order med consults, however the medical floor doc will like you better if you handle the easy stuff and only consult them for the hard stuff (e.g. you give motrin for a inconsequential headache, but if the pt has a stroke, you get the IM doc pronto).

If the pt faces long term inpt care on the psyche unit, you better have good relations with the internal medicine doc when covering the pt--because you still are their primary doc. Make sure the long term care facility's IM doctor is covering the pt's physical needs well.

 

[watermen]

It is totally acceptable to defer the Physical Exam (and also the Interview) in acutely Psychotic patient.

It is definitely understandable to defer certain part of the exam when situation does not permit. However, when a psychiatrist say "DEFER" ...they will NEVER do the physical exam...even when the patient is stabilized...I NEVER NEVER seen them do it....They don't care...and THEY DON'T KNOW how to do it anymore...those resident's stethoscope in the pocket is just full of dust!!!

A lot of psychiatrist I seen does not fit to be a doctor! They are just psychologist who can prescribe medicine. Who only know how to talk...and sometime...these psychiatrists have no empathy on their patient.

Want to see bad practice of medicine?...then see what those psychiatrists do....

and yeah....guess what...when those psychiatrists have the free time in the preceptors room...these people start to bitch about other specialty...esp surgery...start to analyze XYZ singer's personality....this is definitely unprofessional!

 

[gbv]

watermen,

you're in the midst of some bad training.

and I feel very bad for you.

 

[Anasazi23]

Watermen,

Your barely comprehensible post elucidates virtually nothing. I personally have deferred multiple physical exams, and gone back to perform them on multiple occassions.

It might be true that you're in bad training, or that you don't know what to look for. All practicing psychiatrists have completed steps I, II, and III. They know how to conduct a physical, though they may choose not to do one for whatever reason. I'm not saying that all psychiatrists conduct physicals on all their patients - that would be nearly unreasonable. But to make such blanket statements that you do is absolutely untrue.

Insulting an entire band of a medical specialty with such limited experience will win you no credibility.

 

[whopper]

they will NEVER do the physical exam...even when the patient is

They're not doing what they're supposed to be doing.

In your defense, I will say I've seen psychiatrists do this and you know what? That upsets me. I'll sound narcissistic and say that from some attendings I've seen, I'm already convinced I'm better than them, and I was better than them since my 2nd year.

You can only do so much. Just don't do what you're describing these people as doing. They might not be following standard of care or following their Oath. Doesn't mean you have to do the same.

If you ask me part of the problem is we need to regulate ourselves better. If we see our colleagues doing subpar practice we need mechanisms to make sure they don't do that. That goes for all of medicine, not just Psychiatry. I can tell you horror stories from every field. (An anesthesiologist who didn't wear a mask and sneezed into a completely cut open pt, a Ob-Gyn doc that only changed gloves when doing surgery on a different pt...)

I recently won the NJPA's Best Paper contest for 2007. Had a case of a girl who was ingesting rat poison and her INR wouldn't go down after several weeks in the psyche ward, in fact it was going up.

The IM consult was completely off in his assessment (and in his defense, I know him and he's a good doc, just missed the ball on this case). He thought it was because she had a secret stash of rat poison somewhere on the unit. The place was turned upside down trying to find it. We even x-rayed her because we thought she might have had a secret supply hidden in her GI tract. A 24 hr 1 to 1 was placed.

I spent hours scouring the net to figure out why her INR was going up because the IM doc's theory wasn't panning any positive results. Turned out that rat poison had a half life of several months (he thought it was days) and when mixed with acetaminophen, it raises INR. This is something not commonly known and is hardly documented. Even the guys as Poison Control didn't know that.

Had I simply just thrown it to the IM doc's corner that case never would've been solved.

Remember, we're psychiatrists but the pt's medical needs if acute must always take priority over psychiatric needs. We still have to have medical knowledge, and that knowledge will make you a better doctor and person.

 

[zenman]

In every psych hospital I've worked in, a FP doc had a contract to do all the physicals.

 

[Hurricane]

In every psych hospital I've worked in, a FP doc had a contract to do all the physicals.

I think that kind of policy perpetuates the stereotype that psychiatrists aren't "real doctors."

 

[Anasazi23]

Why?

Would you be comfortable with a general medical hospital with no psych unit hiring a full time C/L psychiatrist to see or consult on psychiatric patients or patients exhibiting psychiatric symptoms? Would you rather have the IM doc treat the suspected psychiatric conditions or changes in mental status under the guise of them 'being comprehensive medical doctors?' Then it doesn't seem so unreasonable.

Most state hospitals have an internist on staff to take care of medical issues. It's not a dererence to IM over psychiatry's ability to perform a physical or make a medical differential. Some might argue that it's more comprehensive care to have multiple medical disciplines working with patients.

 

[OldPsychDoc]

I've stayed out of this b/c I know you all are going think I'm a weenie doctor, but frankly, I don't think that it is helpful to the therapeutic alliance to expect our patients to take off their clothes for us.

I think that our role is assessment and treatment of problem behaviors, and these can generally be adequately assessed without us personally conducting a full physical. I rely on PAs and FP moonlighters to conduct full physical exams on my inpatients and coordinate consultations where necessary with med/surg services. I do review labs, PE results, and pay close attention to the management of my patients' many co-occuring medical problems. For example, I've got a young female on the unit right now with a complaint of abcesses on her hips from her habit of skin-popping heroin: I simply do not believe that it is important for my management of her opiate addiction to be the individual who inspects these sores, nor drains them (as she is unnecessarily demanding today--probably to find another way to avoid transfer to residential CD treatment). It IS my responsibility to see that they are fully evaluated, to ensure that she is not febrile or septic, and to communicate with the general surgery service accordingly, since they are the "abcess experts" (and I now have their expert opinion that there is no need for further work-up).

 

[whopper]

Don't know how it works where you are oldpsychedoc. Maybe what you're doing is appropriate given the environment.

But in my neck of the woods--1 Hepatic Encephalopathy, 1-encephalopathy--> which ended up dying on the ICU after we figured out what was going on and got the patient back to medicine, 1 leukemia case that had metastasized to the brain (and that pt ended up dying on the medical floor, after we figured out what was going on and got the pt back to medicine) 1-meningitis, 1-staph aureus infection, 1-myocardial infarction, 1 severed tendon, 1 broken femur, 1 internal bleeding case , dozens of lice & scabies cases have happened during my 2 year stint in inpatient or crisis psychiatry, and I'm not talking cases where these became obvious only after the pt was given to psyche, I'm taking clear and present red flags that the ER or IM floor doc just blatantly missed while trying to turf the patient off to psyche, while writing a completely normal physical exam that obviously was not done.

And these weren't cases where the IM doc or ER doc got the right dx. I got the right dx and told the ER or IM doc they were missing it, and only by finding that dx were those docs willing to take the pt back.

Several of the above were horror stories where the medical or ER attending was blatantly lying or doing borderline malpractice if not malpractice. E.g. I asked the doc "does the pt have asterexis", "No---and by the way, you don't know medicine, I do. You psychiatrists always try to block us giving patients to you".

15 minutes later we get the patient. I check for asterexis--and the pt has it--blatant and obvious, and with his serum ammonia being through the roof.

They said he was schizophrenic--he had no history of it, was in his late 40s, and had acute confusion which they said was psychosis. It was so blatantly hepatic encephalopathy.

So in my neck of the woods you need to do a physical exam. I don't really ask they take their clothes off either. Very few times I had to ask for this. By the time they get to me in inpt or crisis, they're usually already in a hospital gown. If not, I usually only have to visually inspect their belly or legs. I don't have to see them completely nude.

 

[TheWowEffect]

Don't know how it works where you are oldpsychedoc. Maybe what you're doing is appropriate given the environment.

But in my neck of the woods--1 Hepatic Encephalopathy, 1-encephalopathy--> which ended up dying on the ICU after we figured out what was going on and got the patient back to medicine, 1 leukemia case that had metastasized to the brain (and that pt ended up dying on the medical floor, after we figured out what was going on and got the pt back to medicine) 1-meningitis, 1-staph aureus infection, 1-myocardial infarction, 1 severed tendon, 1 broken femur, 1 internal bleeding case , dozens of lice & scabies cases have happened during my 2 year stint in inpatient or crisis psychiatry, and I'm not talking cases where these became obvious only after the pt was given to psyche, I'm taking clear and present red flags that the ER or IM floor doc just blatantly missed while trying to turf the patient off to psyche, while writing a completely normal physical exam that obviously was not done.

And these weren't cases where the IM doc or ER doc got the right dx. I got the right dx and told the ER or IM doc they were missing it, and only by finding that dx were those docs willing to take the pt back.

Several of the above were horror stories where the medical or ER attending was blatantly lying or doing borderline malpractice if not malpractice. E.g. I asked the doc "does the pt have asterexis", "No---and by the way, you don't know medicine, I do. You psychiatrists always try to block us giving patients to you".

15 minutes later we get the patient. I check for asterexis--and the pt has it--blatant and obvious, and with his serum ammonia being through the roof.

They said he was schizophrenic--he had no history of it, was in his late 40s, and had acute confusion which they said was psychosis. It was so blatantly hepatic encephalopathy.

So in my neck of the woods you need to do a physical exam. I don't really ask they take their clothes off either. Very few times I had to ask for this. By the time they get to me in inpt or crisis, they're usually already in a hospital gown. If not, I usually only have to visually inspect their belly or legs. I don't have to see them completely nude.

It seems like ER and IM physicians are incredibaly inefficient in your "neck of the woods" or there is something more to it...

 

[whopper]

I don't think its just where I am.

I work in 3 different hospitals-in two separate systems. Same problems.

Talked to residents from UMDNJ-New Brunswick & Bergen Regional Medical Center-same problem. One resident from Robert Wood Johnson-Cooper in Camden told me for example they got a guy with a punctured lung, and had to battle the IM doc to take the patient back.

One of my attendings worked at Dartmouth (as teaching staff), in several hospitals in Philadelphia & New England--same problems.

He told me this happens in almost every hospital.

Only place I haven't seen this as a problem is in outpatient. So while this may not be happening everywhere, I'm convinced its happening at a lot of places.

"Turfing" happens in a lot of places. Read the House of God. Sarcastic, but also painfully truthful in several aspects of hospital medicine & politics.

 

[Doc Samson]

I don't think its just where I am.

I work in 3 different hospitals-in two separate systems. Same problems.

Talked to residents from UMDNJ-New Brunswick & Bergen Regional Medical Center-same problem. One resident from Robert Wood Johnson-Cooper in Camden told me for example they got a guy with a punctured lung, and had to battle the IM doc to take the patient back.

One of my attendings worked at Dartmouth (as teaching staff), in several hospitals in Philadelphia & New England--same problems.

He told me this happens in almost every hospital.

Only place I haven't seen this as a problem is in outpatient. So while this may not be happening everywhere, I'm convinced its happening at a lot of places.

"Turfing" happens in a lot of places. Read the House of God. Sarcastic, but also painfully truthful in several aspects of hospital medicine & politics.

I agree... My hobby-horse as a consultation psychiatrist is physical illness misdiagnosed as psychiatric (delirium called depression, epilepsy called schizophrenia, etc.), but even outside of these "subtle" distinctions, I remember admitting patients to the inpatient psychiatry unit as a resident that had supposedly been medically cleared, then discovering such easy-to-miss findings as a broken clavicle (tenting the skin, no less) and scabies. Always do a physical exam ASAP, unless there's reason to fear for your safety.

 

[TheWowEffect]

I don't think its just where I am.

I work in 3 different hospitals-in two separate systems. Same problems.

Talked to residents from UMDNJ-New Brunswick & Bergen Regional Medical Center-same problem. One resident from Robert Wood Johnson-Cooper in Camden told me for example they got a guy with a punctured lung, and had to battle the IM doc to take the patient back.

One of my attendings worked at Dartmouth (as teaching staff), in several hospitals in Philadelphia & New England--same problems.

He told me this happens in almost every hospital.

Only place I haven't seen this as a problem is in outpatient. So while this may not be happening everywhere, I'm convinced its happening at a lot of places.

"Turfing" happens in a lot of places. Read the House of God. Sarcastic, but also painfully truthful in several aspects of hospital medicine & politics.

Turfing happens. There is no doubting this reality of staff-based hospital medicine. Everyone wants to work less for the same money. My question is whether we psychiatrists can really take his holier than thou attitude w.r.t. turfing. We have all seen the usual "medically cleared/stable" patients not really cleared or stable. But when there is a post with "I did this" and "I did it right", "they don't know their medicine" etc, there is something else to it.

 

[Doc Samson]

Turfing happens. There is no doubting this reality of staff-based hospital medicine. Everyone wants to work less for the same money. My question is whether we psychiatrists can really take his holier than thou attitude w.r.t. turfing. We have all seen the usual "medically cleared/stable" patients not really cleared or stable. But when there is a post with "I did this" and "I did it right", "they don't know their medicine" etc, there is something else to it.

Of course there's something else to it. One of the major forces that drove me into a career in consultation psychiatry (and keeps on driving me) is the commonplace substandard medical care delivered to any patient with a psychiatric diagnosis. The presence of any psychotropic on a medication list is all too often an excuse to take the easy route of "it's supratentorial." I've seen hypercapnic respiratory failure called "anxiety"; delirium (due to sepsis, refeeding syndrome, metastatic cancer, etc.) called "psychosis", "depression", and "personality disorder"; and a dying patient called "catatonic" - all because they had a pre-existing psychiatric diagnosis. This does not happen in the other direction - I never say "Well, he can't possibly be depressed, he just has diabetes." I am completely in touch with my sense of outrage - you need to be to do the work.

 

[whopper]

when there is a post with "I did this" and "I did it right", "they don't know their medicine" etc, there is something else to it.

Yeah well the "something else to it" may be that particular doc is a jack@##.

But in any case, that doc don't get fired, and I still got to deal with him.

The good thing about being a doctor is we got great job security.

The bad thing is the great job security prevents certain docs from being fired who don't do their jobs, because they can't be easily replaced.

Anyways, I'm not going to be a resident who tries to get an attending fired, even if I think that is what should happen. I might as well just put my head in a guillotine because that'd be easier and faster. I had reported the above type stuff to the attendings and they either don't seem to care (maybe they do but aren't telling me) or they tell me this type of thing happens at every hospital. In any case the cycle continues....

The farthest it went was one night an ER doc tried to push in a patient with an MRSA infection to psyche and when I tried to stop him, he said he'd give an antibiotic (the wrong one for MRSA and oh by the way it'll mess up any chances to culture the bacteria, and he wasn't going to culture it before antibiotic administration). The attending was ticked and reported it to the head of the ER dept. Don't know what happened--but that same ER attending still pulls stuff like this.