General Medical Evaluation and Management of the Psychiatric Inpatient
Fred Ovsiew
David Lovinger
Psychiatrists’ skill in providing general medical care has been in question since the foundation of the profession. In 1894, the prominent American neurologist Silas Weir Mitchell was invited to speak to the American Medico-Psychological Association, the precursor to the American Psychiatric Association. He took note of the geographic isolation of psychiatric practice in the asylums away from the rest of medical practice, and then he said:
When we ask for your asylum notes of cases, or by some accident have occasion to look over your case books, we are too often surprised at the amazing lack of complete physical study of the insane, at the failure to see obvious lesions, at the want of thorough day by day study of the secretions in the newer cases, of blood-counts, temperatures, reflexes, the eye-ground, color-fields, all the minute examination with which we are so unrestingly busy.1
In this chapter, we address general medical evaluation and management of the psychiatric inpatient. The chapter does not aim at comprehensive coverage; a psychiatric patient could have any disease. The goal is to help the psychiatrist gain a deeper scientific and clinical understanding of a set of general medical problems that arise commonly in psychiatric inpatients, so that assessment and intervention occur more thoughtfully, less by rote, and with greater understanding and expertise, whether the psychiatrist seeks consultation or not. The integration of general health care with mental health care raises important policy issues, which are not addressed in this clinically oriented chapter.2
Separate chapters in this volume describe problems in the inpatient psychiatric care of patients with known, active, serious general medical or neurologic comorbidity. We do not duplicate that material. Chapter 5 offers recommendations for a neuropsychiatric approach to differential diagnosis of common psychiatric syndromes presenting for inpatient care. In this chapter, we document the common concurrence of general medical illness in psychiatric inpatients, describe the tools useful for identifying concurrent general medical conditions in psychiatric inpatients and the interpretation of common abnormalities in screening laboratory tests, suggest strategies for clinical and laboratory evaluation when common conditions are suspected, and offer management recommendations for some common general medical problems that arise as the consequence of psychiatric illness or its treatment.
Prevalence of General Medical Illness in the Psychiatric Population
Knowledge of the domain we discuss is not incidental to inpatient psychiatric practice but a core component of it in most, perhaps all, psychiatric inpatient settings, because concurrent general medical illness is so common and so important. Psychiatric inpatients suffer from an excess of general medical illness, compared with the general population, and these disorders are associated with increased mortality. Further, the illnesses are often undiagnosed or unknown to the inpatient treaters. A brief review of the data supporting these assertions is in order.
Many investigations have demonstrated that concurrent general medical disorders are present in excess of the population prevalence in patients with serious mental illness.3, 4, 5 In a large sample of Medicaid patients, those with a psychotic disorder were significantly more likely than those without a psychotic disorder to have each of the eight conditions studied: diabetes, hypertension, heart disease, asthma, gastrointestinal disorders, skin infections, malignancies, and acute respiratory disorders. Heart disease showed the largest differential, with an odds ratio (OR) of 4.24 for the comparison of all psychotic patients with the general population and 3.19 when only non-substance abusers were considered.6 Risk for heart disease may be especially elevated in younger people with serious mental illness.7 In a different sample of chronically mentally ill outpatients on Medicaid, 75% had at least one chronic health problem and 50% had at least two chronic health problems.8 Chronic lung disease was the most common condition; nearly a third of the sample had medium to high severity of chronic pulmonary disease. In a study of privately insured patients, disorders in almost every organ system were significantly more common in patients with schizophrenia than in comparison patients, including neurologic disorders (OR up to 9.76), hepatitis C (OR 7.54), hypothyroidism (OR 2.62), diabetes with complications (OR 2.11), and chronic obstructive lung disease and asthma (OR 1.88 and 1.80, respectively).9
Patients with schizophrenia have a life expectancy approximately 15 years shorter than the general population, almost a 20% reduction.10 A longitudinal study of a schizophrenia cohort found an elevated risk of death (all-cause standardized mortality ratio [SMR]) of approximately threefold, comprising a twofold increase in risk of death for natural causes.11 In a different population, the relative risk of mortality, in comparison with the general population, was 2.59, a significant elevation, even after the marked elevation in risk of death from suicide (relative risk of 9.9) was excluded.12 In yet another sample, comprising patients from a public psychiatric hospital of whom 43% had a schizophrenia spectrum diagnosis, SMRs for chronic pulmonary disease and heart disease were 5.5 and 3.8, respectively.13
Mood disorder similarly is associated with increased mortality from cardiac disease.14 A long-term follow-up of patients hospitalized for mood disorders showed a significantly elevated SMR of 1.41 for causes of death other than suicide and in particular a significantly elevated SMR of 1.63 for “all vascular diseases.”15 In a study of patients with type 2 diabetes, the presence of depression conferred roughly a twofold increase in mortality risk, which remained significant even after adjustment for potential behavioral mechanisms of increased risk.16 Similarly, the risk of myocardial infarction was approximately tripled in those who had been hospitalized for depression (and quintupled in those admitted for psychotic depression), and the elevated risk remained significant when conventional risk factors for myocardial infarction were controlled for.17
Despite such evidence that depression itself, independent of typical risk factors, may elevate risk of adverse health outcomes, clearly “lifestyle” factors such as smoking, diet, and physical inactivity explain a substantial portion of the excess morbidity and mortality found in patients with major psychiatric disorders.18 Obesity is a factor of particular importance. Compelling data suggest that obesity is highly prevalent in the seriously mentally ill and that its elevated rate is in part independent of medication-related weight gain.13,19,20
The toxicity of psychiatric medicines may explain a portion of the elevated mortality rate. Weight gain due to psychotropic drugs is of substantial health importance and an important determinant of quality of life and probably of compliance with medication.21 Fontaine et al. offered a crude estimate of the mortality due to clozapine-induced weight gain; they calculated that it roughly offset the demonstrable suicide-prevention benefit of clozapine.22 This estimate of elevated cardiovascular risk left out of account the additional diabetogenic effect of antipsychotic medicines, which is partly independent of weight gain and due to insulin resistance, and their adverse effects on lipid profile.23
The combination of central obesity, hypertension, insulin resistance with glucose intolerance, hypertriglyceridemia, high low-density lipoprotein (LDL) cholesterol, and low high-density lipoprotein (HDL) cholesterol—the metabolic syndrome—is a major cardiovascular risk factor and is now recognized to be a common consequence of psychiatric medicines. By most estimates, the metabolic syndrome is present in more than one third of severely mentally ill patients, a figure substantially greater than the population prevalence.24, 25, 26 Nonalcoholic fatty liver disease has more recently been recognized as an aspect of the metabolic syndrome and a potential complication of psychotropic drugs.27
Seriously mentally ill patients suffer as well from social and financial obstacles to obtaining medical care. A longitudinal study of patients with schizophrenia offered poignant vignettes of deaths recorded as “avoidable”: patients, carers, and sometimes physicians failed to identify medical illness or to pursue its treatment in an ordinary way.11
Case Vignettes
A middle-aged man died of pulmonary edema shortly after leaving an emergency room; he had failed to wait to be seen. Two female nursing home residents died of pneumonia, which had been untreated despite medical evaluation. A homeless woman who had refused general medical and psychiatric care died of diabetic ketoacidosis.
Indeed, some evidence suggests that medical care of inadequate quality is responsible for a substantial portion of the elevated risk of death. Druss et al. found a 19% increase in 1-year mortality after myocardial infarction for patients with mental disorders, but the differential disappeared with statistical control for indicators of quality of care.28 Such findings emphasize the widely recognized principle that psychiatrists often serve as the gatekeepers (and advocates) for general medical care for their seriously ill patients.
The data in this section justify a high level of attention to concurrent general medical illness in psychiatric inpatients. That such illness is often unknown to the inpatient staff at the time of admission underlines the importance of a thorough clinical approach. Seriously mentally ill patients do not give adequate medical histories,29 and medical records may be hard to obtain in a timely manner. The patients’ mental disorders may have led to inadequate preadmission general medical evaluation, with inadequate history taking and physical and cognitive examination probably the major contributors to missed diagnoses.30, 31, 32
Of additional and urgent concern is that general medical disorders, recognized or unrecognized, may be contributing to or causing the psychiatric symptoms that lead to admission. A review of studies from various psychiatric settings found that more than one fourth of patients had general medical illnesses producing psychiatric symptoms and that more than half of such illnesses were previously undiagnosed.33 In a large study in the California public mental health system, Koran et al. found that more than a third of the patients had important general medical disease and of those the system was unaware of more than half (although the patient was aware of the illness in approximately half the missed cases). Approximately 6% of patients were thought to have diseases producing their mental symptoms, and most of these diseases had been recognized by the mental health system.34 In a more recent study confined to inpatients, Koran et al. reviewed a group of 289 patients in a public-sector inpatient unit.35 Of these patients, 84 (29%) had “active and important physical disorders.” In 3 patients the authors judged that a previously unrecognized disorder was causing or contributing to mental symptoms; in 14 patients, previously recognized disorders were causing or exacerbating the psychiatric symptoms. Therefore for 17/289 (5.9%) patients, a general medical condition was ultimately thought to be directly relevant in the pathogenesis of psychiatric symptoms.
The methods, both of detecting general medical illness and of judging its relationship to psychiatric symptoms, vary substantially among studies, and a secular change in the rate of such causation or of its being missed on initial evaluation is a possibility. Whether the number is relatively small or impressively large, inpatient psychiatrists do not want to miss somatic disease causing psychiatric symptoms in their inpatients.
In a naturalistic study that did not attempt to attribute causation, Lyketsos et al. observed that active concurrent general medical disorders were present in a substantial minority of patients admitted to a tertiary-care psychiatric unit, and they found that their presence was associated with poorer outcomes in regard to psychiatric symptoms and functional status and with increased length of stay.36 They concluded that attention to concurrent general medical disorders was not only good practice in itself but that it might well improve the psychiatric outcome of an inpatient stay.
General medical illness coincident with psychiatric illness, in part related to behavioral factors and causing substantial impairment and mortality; morbidity and mortality consequent to psychiatric treatment; and general medical illness producing the symptoms leading to psychiatric admission or leading to more difficult and less effective psychiatric hospitalizations: these are conceptually distinct categories, but they call univocally for a high level of general medical skill and attention on the part of the inpatient psychiatrist. Moreover, the data reviewed suggest that trying to exclude patients with active general medical illness from admission to psychiatric inpatient units, by insisting on “medical
clearance,” substantially mistakes the needs of the seriously psychiatrically ill. A population of patients in need of psychiatric inpatient care will perforce require general medical care, and it seems wiser for inpatient psychiatrists and facilities to prepare for this than to try to ignore and exclude it.
clearance,” substantially mistakes the needs of the seriously psychiatrically ill. A population of patients in need of psychiatric inpatient care will perforce require general medical care, and it seems wiser for inpatient psychiatrists and facilities to prepare for this than to try to ignore and exclude it.
Medical History Taking in Psychiatric Inpatients
Taking a general medical history should be a routine part of the psychiatric diagnostic interview, but textbooks of diagnostic interviewing pay little attention to this feature of the diagnostic process. For example, a chapter on diagnostic interviewing in a major text indicates that the data collected in a psychiatric interview should include “all medical disorders past and present and their treatments and childhood disorders that involve the central nervous system” (p 794)—a formidable task! However, the remainder of the lengthy chapter offers almost no instruction on how to perform this task.37
In the authors’ opinion, inpatient psychiatrists should not routinely defer taking the general medical history to a consultant. First, the psychiatrist, not the consultant, should be the expert on interviewing psychotic or otherwise severely mentally ill patients. Second, the psychiatrist, not the consultant, should be the expert on what general medical conditions might affect, or even cause, the psychiatric symptoms at hand. Third, the psychiatrist, who often elsewhere in the hospital preaches the virtue of integrating psychological with somatic medicine, should practice this virtue on the psychiatric unit. Fourth, the psychiatrist, if he or she is to manage the patient properly during the hospitalization and after discharge, needs to be closely familiar with the patient’s general medical status. For example, drug interactions may need to be considered. Reading a consultant’s note is just not the same as taking the history oneself. Fifth, as general medical illness and its treatment may be important psychosocial stressors, the psychiatrist needs to hear directly about their nature, chronology, and impact. Sixth, the psychiatrist can take a step toward a therapeutic alliance with certain recalcitrant patients by marking himself or herself as a physician by asking physicianly questions (and performing a physical examination, as discussed in subsequent text). All this, of course, is not to argue against consultation when appropriate, merely to underscore the importance of a personally taken history as delineated here.
The extent of the general medical history obtained by the psychiatrist naturally depends on the clinical situation. In many instances, a brief survey of the patient’s health status with an appropriate review of systems is sufficient. In other instances, details of the patient’s severe or chronic illnesses need to be explored. Whenever possible, medical records should be reviewed to supplement, confirm, and correct the admission interview.
A few simple inquiries can accomplish a great deal. “Have you had any problems with your heart (lungs, liver, kidneys, joints, skin, thyroid gland, blood pressure, sugar [diabetes], cancer)?”—together with appropriate follow-up questions—can elicit much of the needed information.
Case Vignette
A psychiatric resident, having taken the psychiatric history from a new patient with depression, was eagerly observing his attending’s administration of the Hamilton Depression Rating Scale. As he sat back in his chair doing so, thus relieved of the still-new task of formulating questions for the patient and listening “with the third ear” to the answers, he noticed for the first time that the patient had a thyroidectomy scar on her neck. When the supervisor finished, the resident inquired about the scar and learned that the patient had recently stopped taking her thyroid replacement pills.
Along with this “past medical history,” the psychiatric admission interview should include a review of systems. The psychiatrist should be comfortable inquiring about constitutional symptoms (fever, weight loss, malaise, fatigue), endocrine symptoms (heat or cold sensitivity, constipation or diarrhea,
alopecia or change in texture of the hair, change in menses), rheumatic disease symptoms (joint swelling or pain, rash, oral ulcers, dry eyes or mouth, past miscarriages), cardiopulmonary symptoms (shortness of breath, chest pain and its characteristics, irregular heartbeat, cough), and so on. Again, the extent of inquiry should be guided by the clinical situation and a grasp of the “pretest” likelihood of disease based on the epidemiologic data reviewed earlier. Atypical features of the psychiatric presentation—such as late age of onset, unexpected cognitive problems, or the absence of a prodrome or family history—should lead to a greater emphasis on potential discovery of systemic illness explanatory of the psychiatric symptoms.
alopecia or change in texture of the hair, change in menses), rheumatic disease symptoms (joint swelling or pain, rash, oral ulcers, dry eyes or mouth, past miscarriages), cardiopulmonary symptoms (shortness of breath, chest pain and its characteristics, irregular heartbeat, cough), and so on. Again, the extent of inquiry should be guided by the clinical situation and a grasp of the “pretest” likelihood of disease based on the epidemiologic data reviewed earlier. Atypical features of the psychiatric presentation—such as late age of onset, unexpected cognitive problems, or the absence of a prodrome or family history—should lead to a greater emphasis on potential discovery of systemic illness explanatory of the psychiatric symptoms.
Taking the history of past cerebral disease is discussed in Chapter 5.
THE PSYCHIATRIC PHYSICAL EXAMINATION
“Good psychiatry begins with a responsible Doctor undressing the patient and carrying out a proper physical examination.”
— Pediatrician and psychoanalyst (but not psychiatrist) Donald Winnicott (quoted by Issroff38)
Whether psychiatrists should perform physical examinations—and, if they should, whether they actually do—has been repeatedly addressed in the psychiatric literature over the past several decades.39 Some clinicians have argued that the physical contact between psychiatrist and patient is unwise and that in any event psychiatrists lack the necessary skills to perform an adequate examination. The latter point is quite possibly correct, although the evidence as to the skills of internists is not reassuring either.40 However, skills in physical diagnosis will not be improved by their neglect; rather, such skills should be taught to trainees and practiced, as other diagnostic skills are practiced, through one’s career.41
That physical examination by psychiatrists has adverse emotional consequences has often been taken for granted, although powerful voices have been raised to the contrary, as the epigraph to this section illustrates. At the height of psychoanalytic dominance in American psychiatry, the psychiatrist and psychoanalyst Karl Menninger wrote:
The physical examination of the psychiatric patient is not only a diagnostic procedure, but may constitute one of the most important steps in the therapy. Sometimes it is indeed the very keystone of the therapeutic relationship. It serves to identify the physician in his professional capacity, and to establish, by means of a now familiar and conventional procedure, a confidence in the examiner as a doctor. … The “laying on of hands” has a deep and powerful significance to the patient. … Personally I doubt if it causes as many difficulties as does its omission or its delegation to others. It may be that we psychoanalysts rationalize the fact that some of us do not like to do physical examinations, or do not feel competent to do them properly, and discard or delegate a valuable medical prerogative.42 (pp. 48-49.)
Of course, this is not to deny potential complications of the psychiatrist’s performing a physical examination (as Menninger sensitively described in parts of the passage not quoted). Proper facilities must be available, not always the case on a psychiatric inpatient unit. In most instances, in part because of the potential ambiguity of “laying on of hands,” especially for an acutely disturbed psychiatric patient, the physician should be accompanied by a “chaperone,” for example a unit nurse or, on a teaching unit, one or more trainees. The chaperone should as a rule be of the opposite gender to the psychiatrist. In certain instances (perhaps the hospital care of a patient in intensive psychotherapy with the psychiatrist), physical examination may be unwise. At times, the physical examination allows the patient and doctor to discuss matters that were ignored, missed, or minimized during the preceding interview, for example, the patient’s feelings about a disfiguring injury or the origins of scars from self-cutting. By performing an examination, the physician can bring these facts into the conversation. At other times, a patient’s misinterpretation of the procedure is clear during the examination and should be addressed explicitly by the examiner.
What has perhaps been lacking is the construction of a physical diagnostic approach to psychiatric patients that emphasizes the domains of concern and the likely findings. What is required is a psychiatric physical examination, just as other specialists have taken the physical diagnosis toolbox
and chosen instruments from it as being of special use in the patient populations of interest to them. Fortunately, not only are there excellent texts of physical diagnosis,43,44 which pay attention to the sensitivity and specificity of traditional maneuvers, but also some psychiatric authors have begun the process of constructing a psychiatric physical examination.45, 46, 47, 48 A fuller discussion of the psychiatric physical examination is offered elsewhere.49, 50, 51 Here we briefly highlight findings that the inpatient psychiatrist should be closely familiar with. Somewhat artificially, for the purposes of exposition the neurologic examination is discussed in a different chapter, along with other aspects of the neuropsychiatric evaluation.
and chosen instruments from it as being of special use in the patient populations of interest to them. Fortunately, not only are there excellent texts of physical diagnosis,43,44 which pay attention to the sensitivity and specificity of traditional maneuvers, but also some psychiatric authors have begun the process of constructing a psychiatric physical examination.45, 46, 47, 48 A fuller discussion of the psychiatric physical examination is offered elsewhere.49, 50, 51 Here we briefly highlight findings that the inpatient psychiatrist should be closely familiar with. Somewhat artificially, for the purposes of exposition the neurologic examination is discussed in a different chapter, along with other aspects of the neuropsychiatric evaluation.
General Appearance
Height and weight should always be measured on hospital admission, and the body mass index can be calculated from these figures (e.g., using an online calculator such as the one found at http://nhlbisupport.com/bmi/bminojs.htm). Short stature or unusual height, both assessed in relation to the patient’s biological family, raise questions of developmental disorders (fetal alcohol syndrome, mitochondrial disorders, Down syndrome, homocysteinuria, Marfan syndrome, etc.). Weight loss should not be attributed to behavioral factors (such as depression) without further consideration of systemic illness, such as a neoplasm. Weight gain may be due to psychiatric medicines but also to an endocrinopathy. Along with weight and height, admission assessment should include measurement of waist circumference. Waist circumference is an element of the metabolic syndrome and marks the contribution to cardiovascular risk of a central distribution of fat accumulation.52
Vital Signs
Abnormalities of pulse, blood pressure, respiratory rate, and temperature should never be discounted as consequences of the patient’s psychiatric state. To be sure, at times an anxious or depressed patient has mild tachycardia. Catatonic patients, even while immobile, may show tachycardia as a manifestation of overarousal. Nevertheless, abnormal vital signs always require attention.
Elevated heart rate may represent sinus tachycardia or a ventricular or supraventricular arrhythmia. (Tradition to the contrary notwithstanding, normal heart rate is 50 to 90.53) An electrocardiogram should be obtained to differentiate among these possibilities. Sinus tachycardia may derive from various pathophysiologies (see Table 4.1). Of these, volume depletion and pulmonary embolus (both possible consequences of immobility in psychiatrically ill patients) deserve mention as common, dangerous, and potentially lacking other immediate red flags. In any patient on an antipsychotic (or other dopamine-blocking drug), tachycardia not susceptible to an alternative immediate explanation should raise consideration of neuroleptic malignant syndrome. Although tachycardia alone does not meet the syndromal criteria, not infrequently in the earliest (and most easily reversible) stages only a partial syndrome is present. Similarly, tachycardia can be a feature of the serotonin syndrome.
TABLE 4.1 SOME CAUSES OF SINUS TACHYCARDIA | |||||||||||||
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Case Vignette
A late adolescent with schizophrenia was hospitalized for osteosarcoma. On the oncology service, he was treated with haloperidol and risperidone concurrently. On transfer to a psychiatry floor, he was consistently tachycardic but had no other abnormal physical findings (except the absence of a leg). Nonetheless, creatine kinase (CK) was measured and was elevated. Laboratory data did not reveal evidence of infection. In the absence of other explanations for either tachycardia or elevated CK, the antipsychotic drugs were stopped, and the tachycardia immediately ceased; CK elevation resolved over the next few days.
Tachypnea may derive from chronic pulmonary disease, very common in the chronically mentally ill,8 or a more acute process, such as pulmonary embolus. Some clinicians have argued for measurement of oxygen saturation by pulse oximetry as a routine vital sign. Yawning occurs with sedation but also in opiate withdrawal and as a consequence of serotonergic and dopaminergic drugs.54 Sighing, on the other hand, appears to be nonorganic. Irregular respiration, which may be attributed to anxiety, occurs more frequently than realized as a manifestation of tardive dyskinesia.
Blood pressure should be measured with the patient supine or sitting (with the arm at the level of the heart) using a cuff with a bladder that covers at least 80% of the arm’s circumference. The patient should be at rest for at least 5 minutes before the measurement is made; many expert physical examiners measure the blood pressure late or last in the examination. Measuring orthostatic pulse and blood pressure on admission may detect dehydration and provides a baseline should the patient have an adverse reaction to medication. To obtain orthostatic vital signs the clinician should perform first supine and then standing measurements with the latter taken 1 minute after the patient assumes the upright posture.
Elevated body temperature requires immediate attention. Infectious or inflammatory disease, adverse drug reactions, neoplasms, and other conditions can produce fever, which is defined as a temperature higher than the 99th percentile of the normal range. Because body temperature varies during the course of the day by approximately 0.5°C (0.9°F), different values apply in the morning and the evening, with the upper limit of normal in the evening being 37.7°C (99.9°F); tympanic membrane temperature is commonly lower than oral temperature by 0.4°C (0.7°F). Despite these complications, ordinarily a temperature simply >38°C (100.4°F) is taken as a fever requiring evaluation. Any patient on antipsychotic agents should be considered suspect for neuroleptic malignant syndrome unless an immediately compelling alternative explanation for fever is identified, and serotonin syndrome must be considered in appropriate circumstances.
Head, Eyes, Ears, Nose, and Throat
Minor physical anomalies relevant to neurodevelopmental disorders, including psychosis, cluster in this region. A V-shaped palate, “cuspidal ear” (with a sharp angulation of the external ear), and reduced head circumference can be identified at the bedside.55,56 Cleft lip and palate are associated with frontal lobe disorder both anatomically and neuropsychologically.57 Dentition should be noted as a potential domain of ill health in the chronically mentally ill.58,59 Uveitis, oral ulcers, and sicca symptoms (dry eyes, dry mouth) are associated with autoimmune disease.60 Details of assessing visual and auditory acuity are discussed in Chapter 5.
Neck
Neck stiffness should be sought in a delirious patient. Thyroid enlargement or signs of previous thyroid surgery (as in the case mentioned in an earlier vignette) should be assessed.
Heart and Vessels
Observation of the jugular venous pressure is crucial in assessment of volume overload and congestive heart failure, although estimation of right-sided pressures is difficult for those without much practice. Pedal edema may signify volume overload, hypoalbuminemia, or an adverse drug reaction. Distal pulses should be palpated.
The stethoscope, sometimes forgotten, and its use have long been the hallmark of the physician.39 Auscultation of the carotids for bruits is simple and apparently relevant to cerebrovascular disease but an unfortunately poor index of low flow. Auscultation of the heart can reveal the S3 of heart failure, the S4 of left ventricular stiffness, the pericardial knock or rub of pericardial disease, and the well-known array of murmurs. The latter are relevant to stroke, infectious endocarditis, and numerous other conditions. One of the authors well recalls, as a resident, finding the murmur of a ventricular septal defect in a young schizophrenic man; in distant retrospect, the diagnosis of psychosis related to the velocardiofacial syndrome (22q11.12 deletion), then unknown, can only be conjectured.
Lungs
As discussed earlier, chronic pulmonary disease is highly prevalent in the chronically mentally ill. Auscultation for breath sounds may help identify patients with emphysema (wheezing, prolonged expiratory phase) as well as those with other acute and chronic lung disorders.
Abdomen
Signs of liver disease, such as ascites and liver enlargement or tenderness, should be sought especially in patients with alcohol abuse.
Laboratory Evaluation of Psychiatric Inpatients
Laboratory tests are widely used for screening purposes upon psychiatric admission. “Screening” in this context refers to obtaining laboratory data when specific indications for the test do not emerge from the history or physical examination. Therefore, obtaining a chest x-ray on every patient admitted to a psychiatric unit would be “screening;” obtaining a chest x-ray on a patient who has a cough and fever would not. Screening may aid in the detection of unrecognized disease, especially when history taking and physical examination are hampered by the patient’s psychiatric illness; may make both patient and physician more confident of the absence of disease; and may provide baseline data should developments require further assessment of laboratory parameters (e.g., if treatments may alter laboratory findings). Often studies of the utility of screening tests take into account only the first of these purposes.
No consensus exists on an appropriate panel of screening laboratory tests for psychiatric inpatients.61,62 However, the available data suggest that an extensive battery of tests is not cost effective and moreover may be clinically misleading. The false-positive rate of even a relatively specific laboratory test is high if the pretest probability of a positive result (i.e., the prevalence of the true-positive result in the population) is very low. Therefore, scattershot testing is likely to produce false-positive results that lead to further testing and to a satisfying feeling of being careful and thorough on the doctor’s part, a feeling that does not correspond to any benefit for the patient. A competent history and physical examination, by allowing an estimate of the pretest probability of disease, make the laboratory tests more informative. Furthermore, as already discussed, evidence suggests that history taking and examination are the best techniques for uncovering general medical illness in psychiatric inpatients.30,31
A further limitation on the practice of ordering extensive batteries of tests is imposed by the common readmission of chronically mentally ill patients. Whatever the value of a screening laboratory panel, surely its value is far less when the patient is readmitted the following month. Review of available data should take the place of rote test ordering.
Therefore, the authors recommend that only a limited panel of tests be undertaken beyond those arising from findings in the history and examination. In certain populations, notably the elderly, substance abusers, and those with severe psychiatric or social obstacles to obtaining good medical care, a more extensive laboratory screening approach may be appropriate. The authors tentatively recommend a screening battery including a complete blood count, a chemistry panel (including fasting glucose, electrolytes, renal function tests, CK, liver enzymes, and albumin), thyrotropin and free thyroxine (see subsequent text), cobalamin (vitamin B12, see subsequent text), a serum pregnancy test in women of reproductive potential, and urine toxicology. A screening role for the sedimentation rate, chest x-ray, and electrocardiogram is not supported by available data, although certainly these and other tests may be indicated by the history and physical examination. Routine urinalysis is often suggested in the literature, but evidence for its utility as a screening test is lacking. Certain other screening tests are indicated under specific circumstances, as discussed in more detail in subsequent text. These include tests for syphilis, measurement of lipids (for which there are consensus guidelines), and assays for human immunodeficiency virus (HIV), hepatitis C, and tuberculosis (TB) infection in patients with risk factors.
A more detailed discussion of the interpretation and use of findings in commonly ordered laboratory tests follows.
THYROID DISEASE
The thyroid gland secretes thyroid hormone in the form of thyroxine (T4) and some triiodothyronine (T3). Much of circulating T4 is protein bound, and the unbound (free) portion can be measured as the free thyroxine index (FTI) or directly (fT4). T4 is converted in peripheral tissues to the metabolically active form of the hormone, T3, and a biologically inactive form, reverse T3 (rT3). T4 and to a lesser extent T3, by feedback at the level of the pituitary, influence the level of the pituitary hormone thyrotropin (thyroid-stimulating hormone [TSH]), which regulates secretion of T4. Thyroid disease is often due to an autoimmune process, associated with antibodies to thyroid peroxidase (antiTPO) and thyroglobulin (antiTg). Overt primary hypothyroidism is marked by elevated serum TSH with decreased fT4 and T3; hyperthyroidism due to thyroid disease is indicated by suppression of serum TSH, usually to undetectable levels, with elevated T4 or, at times, an increase of T3 only (T3 thyrotoxicosis). Central thyroid disease, although uncommon, produces a different pattern of abnormalities in thyroidal laboratory tests (discussed briefly in subsequent text).
Related posts:
The Ins and Outs of 200 Years of Psychiatric Hospitals in the United States
Psychosocial Approaches in Inpatient Psychiatry
Psychiatric Education on the Inpatient Unit
Hospital Treatment of Depression and Mania
The Patient with Borderline Personality Disorder
Evaluation and Management of Substance Use Disorders on the Inpatient Psychiatric Unit
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