Year: 2010

What Should be Considered for "Medically Clearing" a Patient with Psychiatric Problems?

Patient Presentation
A 12-year-old male came to the emergency room for increasing behavioral changes over 6 weeks. He was known to have autism and disruptive behaviors and he was biting and throwing objects more. He was also sleeping less. The family usually was able to manage him but they felt that he now needed to be evaluated. They had called their local medical physician who did not feel comfortable managing this change and therefore the child was sent to the regional children’s hospital. The history showed no medication changes (he was taking an antidepressive and an antiepileptic medication) and he was using the same brand of medication. There were no new medications in the household. There were no social changes. He did have a cold 3 weeks before, but was not ill currently. The family history was positive for diabetes and kidney disease. The review of systems was negative.

The pertinent physical exam showed a compliant male until an attempt was made to examine him. He then tried to hit and bite the examiner. The examination was completed with the assistance of the parents who were able to calm him. His growth parameters were 50-75%. These were increased from the previous trend of 25-75%. Genitourinary examination showed Tanner II pubic hair. Neurologically he was alert and appeared oriented to the hospital, examiner and family. His repetitive speech and answers to questions were appropriate for his baseline per his parents. The rest of his physical examination was negative. The laboratory evaluation included a complete blood count, electrolytes, liver function tests, erythrocyte sedimentation rate and urine drug screening which were all negative. The emergency room physician contacted the pediatrician for a telephone consultation to medically “clear the patient” before she called child psychiatry. The pediatrician noted that child did not appear to have an intercurrent illness, or by history or physical examination appeared to have a new illness. The child also had a stable social situation including no concerns about child abuse or neglect. When the pediatrician asked about recent weight and medicine changes , the emergency room physician said that the family had noted that he seemed to have recently increased his weight and height but that no changes in his medication had been made for a long time. The pediatrician noted that the diagnosis of possibly outgrowing the medication dosage and/or had recently initiated puberty which could also possibly alter his behavior. He did note that other testing could be done such as thyroid, cardiac and neuroimaging but that the history and physical examination did not appear to support it. Several days later the emergency room physician saw the pediatrician and told him that the parents felt comfortable with what had been done in the emergency room and felt they could continue to manage his behavior at home. They were going to call their son’s psychiatrist to schedule an appointment the day after the emergency room visit. Several months later, the pediatrician encountered the patient again for a pre-operative evaluation for a dental procedure. Upon seeing the weight changes, the psychiatrist had adjusted his medications and his behavior improved.

Discussion
Emergency room and psychiatric health care professionals may consult a pediatric health care provider to help provide initial medical evaluation and ongoing medical care to patients with primary or concurrent psychiatric problems. Sometimes, medical clearance of the patient is needed before a patient is allowed to be placed in an inpatient psychiatric facility.

The medical evaluation for psychiatric illnesses depends on the presentation and underlying medical conditions. Inadvertent or intentional overdose of medication, known medication side effect or medication interactions, and drugs of abuse are common problems that present to the emergency room. A medication review including those taken by the patient and those available to the patient both legally and illegally is important in the history. Also drug interaction profiles can often identify known drug side effects or known drug interactions.

For children, intercurrent illnesses are often the cause of behavior changes. Children with known psychiatric or neurological problems can be particularly perplexing in deciding if it is a change or progression of the underlying medical or psychiatric problem, medication problem, intercurrent illness or development of a new disease process. Social changes also impact the medical condition. For example, a child may be in good seizure control, but becomes homeless and is not able to take the medication properly which causes increases in his/her temporal lobe epilepsy.

A thorough history including psychiatric and social history, and physical examination including a mental status examination are important in the initial evaluation. Patients with violent or unpredictable behavior need to be protected from hurting themselves and health providers and caregivers. This may necessitate use of medical and chemical restraints. Consultation with psychiatric professionals even if the patient is not medically stable is important so that appropriate psychiatric care can be initiated.

Learning Point

Studies have been done which look at the utility of routine or semi-routine laboratory testing with varied results. History, physical examination, and differential diagnosis should guide the use of laboratory testing.

A list of common medical tests that can be considered for evaluating a patient with psychiatric problems and possible medical causes are below:

  • Complete blood count
    • Anemia
  • Electrolytes including BUN, creatinine, glucose and calcium
    • Electrolyte imbalance
    • Diabetes
    • Hypocalcemia
    • Hypoglycemia
    • Adrenal disease (hypo- and hyper-)
    • Porphyria
    • Uremia
  • Liver function tests
    • Hepatic insufficiency and failure
    • Reye’s syndrome
  • Thyroid studies
    • Thyroid disease (hypo- and hyper-)
  • Toxicology screening including testing for specific drugs or problems
      The list of drugs is extensive but common ones include polypharmacy, anticholinergic agents, benzodiazepines, corticosteroids, nonsteroidal
      anti-inflammatory drugs, opioids and selective serotonin reuptake inhibitors.

    • Alcohol
    • Drugs of abuse
    • Carbon monoxide
    • Heavy metals
    • Wilson’s disease
  • Lumbar puncture
    • Encephalitis
    • Meningitis
  • Electrocardiogram/echocardiogram
    • Cardiac failure
    • Bacterial endocarditis
    • Pulmonary insufficiency
  • Cranial imaging – if intracranial pathology is suspected
    • Brain abscess
    • Intracranial hemorrhage
    • Tumor
  • Chest radiograph
    • Pulmonary insufficiency
  • Electroencephalogram
    • Epilepsy – especially temporal lobe
  • Rheumatological laboratories – C-reactive Protein, Erythrocyte Sedimentation Rate
    • Lupus
    • Polyarteritis nodosa
  • Infectious disease laboratories – culture, microscopic or rapid diagnostic testing
    • Malaria
    • Typhoid fever
  • Nutritional disease
    • Niacin deficiency

Questions for Further Discussion
1. What are the indications for the proper use of medical and/or chemical restraints?
2. What procedures need to be followed to properly voluntarily or involuntarily admit a patient to a psychiatric facility?
3. What are risk factors for suicide attempts in children and teenagers?
4. What mental health services are available for children and teenagers in your local community?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Autism and Child Behavior Disorder.

To view current news articles on this topic check Google News.

Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:789-802.

Sood TR, Mcstay CM. Evaluation of the psychiatric patient. Emerg Med Clin North Am. 2009 Nov;27(4):669-83, ix

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    • How Many Food Defects are Allowed?

    Patient Presentation
    In late September 2010, a leading infant formula manufacturer voluntarily recalled some infant powdered formula because they “detected the remote possibility of the presence of a small common beetle in the product produced in one production area in a single manufacturing facility.” In the clinic, several pediatric residents were aghast that manufacturing incidences like this could occur. A faculty pediatrician then talked about her own experiences as a young adult working in a fruit processing plant. She told about the great care taken with mechanical processing and with the workers to produce exceptional quality fruit, yet unavoidable defects were uncommonly found such as fruit pits and insect parts. She pointed out that even with locally grown food, there are still defects that are unavoidable but most defects are not harmful. A couple of residents shared her view, but others didn’t.

    As she prepared dinner that night using food from her own garden that her children had just picked, the pediatrician had to smile as she found a spider in several basil leaves, and gnaw marks from slugs on the green beans.

    Discussion
    During food growing, processing and preparation, appropriate steps to ensure the quality and wholesomeness of the food are important. It is not economically or humanly possible to detect and eliminate all natural or unavoidable defects in food that present no health hazards to humans. While some of these defects may cause an odious feeling such as insect parts or rodent hair, these do not pose inherent hazards to health. The Food and Drug Administration (FDA) sets standards for various foodstuffs that manufacturers must follow. The “…levels do not represent an average of the defects that occur in any of the products–the averages are actually much lower. The levels represent limits at which FDA will regard the food product “adulterated”; and subject to enforcement action….” These food defects are distinctly different than food adulteration. One example of adulteration was the purposeful addition of melamine to infant formula in China in 2008. Melamine is a known toxin to humans.

    Food defects include insect, parasites, mammalian excreta, rodent hair, mold, sand and grit, fruit pits, shells, rot and decomposition.

    For example, cloves naturally have a stem and a certain amount of them are allowed. Canned tomatoes can have insect parts and mold. Raisins can have sand, grit and mold. Cocoa powder that is manufactured is allowed to have mold, insect parts and mammalian excreta.

    Personal food handling and preparation is always important. Storing food at the proper temperature (i.e. room, chilled or frozen), washing fruits and vegetables, cooking for the proper length of time and to the proper temperature, and serving and maintaining food at the proper temperature are musts for consuming healthy food.

    Learning Point
    The FDA has the Defect Levels Handbook – Levels of natural or unavoidable defects in foods is available online,

    The FDA also provides information about the regulation of commercial infant formula, including an overview of manufacturing processes for infant formula.

    Questions for Further Discussion
    1. How should pumped breast milk be properly handled and stored?
    2. How should infant formula be properly handled and stored?
    3. Most fruits and vegetables can be prepared at home for infants. What vegetables should not be prepared at home because of health risks?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Food Safety and Infant and Newborn Nutrition.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    United States Food and Drug Administration. Defect Levels Handbook.
    Available from the Internet at http://www.fda.gov/food/guidancecomplianceregulatoryinformation/guidancedocuments/sanitation/ucm056174.htm (cited 10/22/10).

    United States Food and Drug Administration. Infant Formula.
    Available from the Internet at http://www.fda.gov/Food/FoodSafety/Product-SpecificInformation/InfantFormula/default.htm (rev. 9/23/10, cited 10/22/10).

    United States Food and Drug Administration. Powdered Infant Formula: An Overview of Manufacturing Processes.
    Available from the Internet at http://www.fda.gov/ohrms/dockets/ac/03/briefing/3939b1_tab4b.htm (cited 10/22/10).

    ACGME Competencies Highlighted by Case

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    16. Learning of students and other health care professionals is facilitated.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    • What Causes Hypocomplementemic Glomerulonephritis?

    Patient Presentation
    A 10-year-old female was admitted to a regional children’s hospital because of headache and hypertension. The headaches had been present intermittently for 1 week but were not increasing in intensity. They were relieved with rest and ibuprofen. She complained of some intermittent leg pains also. About 3 days prior to admission, her mother noted increased puffiness of her face and abdomen. She had no changes in urination. On the day of admission, the headache returned with increased intensity and she had emesis x 3. Her primary care provider noted a blood pressure of 156/108 and periorbital edema. Urine dipstick in his office showed marked protein and blood. She was then referred. The past medical history was negative. The family history was positive for several family members with lupus, but no other autoimmune, nephrology or gastrointestinal problems. The review of systems showed at least a 10 pound weight gain per mother’s estimate, but no fever, chills, rashes, eye changes, or mucous membrane changes. She denied recent illnesses or travel.

    The pertinent physical exam showed a child with moderate pain secondary to headache. Blood pressure was 131/85, pulse of 90, and respiratory rate of 32. She had periorbital and peripheral edema. Lungs had mild crackles at the bases. Heart was tachycardic with a flow murmur. Abdomen was soft and slightly tender throughout, but the abdomen was not tense. A fluid wave was inconsistently present. The rest of her examination was negative. The laboratory evaluation included a urinalysis which showed a specific gravity of 1.030, pH = 6, with +1 ketones and bilirubin, and +3 blood and protein. The microanalysis showed numerous red blood cells but no white blood cells. There were some red blood cell casts. Electrolytes showed a sodium of 143 mEq/l, potassium of 4.4 mEq/l, BUN of 44 mg/dl and creatinine of 1.7 mg/dl. Total cholesterol was 126, high density lipoprotein of 36 and low density lipoprotein of 79. C-reactive protein was < 0.5 mg/dl. C3, C4 and CH50 were significantly low. CBC and bleeding profile laboratories were normal. Her antistreptolysin O titer was 738 IU/ml (normal 0-240).

    The diagnosis of presumed acute post-infectious glomerulonephritis was made. Additional history revealed treatment for streptococcal pharyngitis 3 weeks before admission. The patient’s clinical course showed that she was treated with fluid restriction, diuretics and anti-hypertensive medications. Within 3 days, the BUN and creatinine began to decrease toward normal. She had no oliguria. Because of the strong lupus family history, additional rheumatological testing was done which was all negative. The patient was discharged on day 4 still on antihypertensive medications. At followup 6 weeks later, she was reported to be back to her normal self including no edema, headache and was her normal weight. She still had slightly high, intermittent blood pressures but her electrolytes and urine were normal with a creatinine of 0.6 mg/dl. She was to stop her anti-hypertensive medication and monitor blood pressures at home with telephone followup in 1 week.

    Discussion
    Post-infectious glomerulonephritis (GN) is very common and 80-90% of cases are caused by acute poststreptococcal glomerulonephritis (APSGN) which is an immune-complex mediated problem.
    Typically:

    • Infection precedes the nephritis generally by a few weeks and may be difficult to identify. It can be caused by nephritogenic strains of Group A, Beta-hemolytic Streptococcus from both pharyngitis and dermatological infections, other bacteria, viruses and parasites. Interestingly, usually acute rheumatic fever and APSGN do not occur together.
    • Abrupt onset of edema, hematuria, usually hypertension, with usually mild renal failure.
    • Patients begin recovering usually starting within 1 week for edema and 2-3 weeks for hypertension. Urinalysis may be abnormal for several years though, especially microscopic hematuria.

    Lab testing:

    • C3 level low (< 50% normal) and generally returns to normal in 3-6 weeks
    • C4 levels usually are normal (if low, consider other causes)
    • Antistreptolysin O titre is positive in ~80% of children
    • Other tests are often ordered to eliminate other disease causes and to help treatment

    Supportive care is the mainstay of treatment with careful fluid management including fluid restriction and diuretics, electrolyte management (including sodium restriction) as necessary, antihypertensive medications to control hypertension, and antibiotics only if an infection is identified.
    If the clinical presentation does not support an initial diagnosis or clinical course consistent with the diagnosis of APSGN such as having increasing hematuria or anemia, uncontrollable hypertension, progressive renal insufficiency such as oliguria, azotemia or worsening laboratory tests, then renal biopsy may be necessary to identify other potential causes of GN.

    Learning Point
    Hypocomplementemic glomerulonephritis is caused by one of 4 diseases:

    • Acute post-infectious GN (usually APSGN)
    • GN associated with chronic infections such as shunt nephritis or bacterial endocarditis
    • Membranoproliferative GN
    • Lupus GN

    Questions for Further Discussion
    1. What are indications for a renal biopsy?
    2. What are indications for renal dialysis? Review a previous case here.
    3. What are the components of nephrotic syndrome?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Kidney Diseases and Streptococcal Infections.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1677-1681.

    Singh GR. Glomerulonephritis and managing the risks of chronic renal disease. Pediatr Clin North Am. 2009 Dec;56(6):1363-82.

    Bhimma R. Acute Poststreptococcal Glomerulonephritis. eMedicine.
    Available from the Internet at http://emedicine.medscape.com/article/980685-overview (rev. 1/7/10, cited 10/11/10).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital