Physical Examination in Psychiatric Patients –“Myth or Reality” – Where are the guidelines?
People with mental illness have increased morbidity and mortality in comparison with the general population1. Physical illness may manifest with psychiatric symptoms2. Also prescribed drugs may have physical side effects, so the patient’s baseline physical findings should be documented prior to commencement of treatment. In an article published by the Royal College of Psychiatrists (2009), the West London Mental Health Trust advises that all patients should have a comprehensive physical examination within 24 hours of admission3.
We sought to ascertain if physical examination was being performed and documented in adults being admitted under the Kerry General Hospital Mental Health Services. Due to the absence of a gold standard guideline, we agreed upon a list of eight criteria that constituted a basic but thorough physical examination as follows; level of consciousness, temperature recorded, BMI recorded, cardiovascular, respiratory, abdominal, peripheral neurological / locomotor and cranial nerves examination. These criteria were face validated amongst the authors.
We included questions on whether or not a physical examination had been performed on admission, or within 24 hours of admission as well as determine if the patient’s capacity to decide on refusal had been established and documented. The admission notes and subsequent notes within 24 hours of the first 50 adult admissions in November 2015, to the Mental Health Unit in KGH were inspected to evaluate if physical examination had been performed and documented. The results of the first cycle were shared with all NCHDs via departmental teaching, emails and social media. The second cycle began on 19/02/2016 after a 2 week interval.
In the first cycle, 17 patients out of the 50 did not have a physical examination on admission. Three patients refused examination. Of the 17 who were not examined on admission, 11 had still not been examined within the 24 hour mark, with no reason documented. In the 2nd cycle, 30 patients had physical examination on admission, 20 did not. Six patients refused examination with other reasons given for 4 cases. Seven of the 20 patients subsequently had a physical examination within 24 hours. The study set out to encourage NCHDs to carry out physical examination on patients admitted into the psychiatry unit as well as to improve the quality of their documentation. Capacity to decide against physical examination was documented in only one case which was in the second cycle.
The cardiovascular, respiratory and abdominal examinations were the most consistently carried out. Documentation of capacity was consistently very poorly recorded. This raises an issue as regards the comfort level of NCHDs in assessing capacity in patients with mental illness. The importance of performance of physical examination and documentation of same for patients with mental illness cannot be overstated. It is important to raise awareness amongst doctors at all levels. The difficulty in altering established habits amongst doctors was evident from some of our results, but there were nonetheless some encouraging trends observed between cycles which shows that change can be effected with focused and consistent awareness campaigns.
Dr Abimbola Akintola1, Dr John Dunlea1, Dr Navroop Johnson2
1South West Specialist Training Programme in General Practice
2Department of Psychiatry, University Hospital Kerry, Tralee, County Kerry.
1 Gates J1, Killackey E2, Phillips L3, Álvarez-Jiménez M2. Mental health starts with physical health: current status and future directions of non-pharmacological interventions to improve physical health in first-episode psychosis. Lancet Psychiatry. 2015 Aug; 2(8):726-42. doi: 10.1016/S2215- 0366(15)00213-8
2 Richard C.W. Hall, MD; Earl R. Gardner, PhD; Sondra K. Stickney, RN; August F. LeCann, PhD; Michael K. Popkin, MD. Physical Illness Manifesting as Psychiatric Disease II. Analysis of a State Hospital Inpatient Population. Arch Gen Psychiatry. 1980; 37(9):989- 995.doi:10.1001/archpsyc.1980.01780220027002.