Harniess 01

Importance of Physical Examination in Mental Health

Assessment

Dr D A HarniessMBChB MRCGP DCH DRCOG

Learning Objectives

• Rationale for physical examination in mental health

• Considering organic causes for different psychiatric presentations

•Tailoring physical examination to different mental health presentations

•Recording and documentation of findings

•Relationship of physical problems to mental health

Pair Work

Why do you think it is important to consider a physical examination in someone presenting with a psychiatric illness?

Rational for Medical Examination in Mental Health Presentations

• Lessons of history – many inpatients of mental health institutions had underlying organic cause for psychosis/depression

• Report of undetected infectious disease and metabolic conditions in psychiatric inpatients1

• Identifying a physical cause for depression allows appropriate treatment to be given that may well ease the depression e.g. pain control

1 Rothbard, AB., Blank, MB., Staab, JP et al Previously Undetected Metabolic Syndromes and Infectious Diseases Among Psychiatric Inpatients Psychiatric Serv Amercian Psychiatric Association April 2009 60:534-537

Rational for Medical Examination in Mental Health Presentations

• Temporal lobe epilepsy or brain tumour manifesting as unusual behaviour often misdiagnosed as psychiatric condition

• Need to consider postpartum thyroid disease or anaemia in postnatal depression/ psychosis

• Association between anxiety disorder and hyperthyroidism & asthma

• Coronary Heart Disease and link to depression

1 Rothbard, AB., Blank, MB., Staab, JP et al Previously Undetected Metabolic Syndromes and Infectious Diseases Among Psychiatric Inpatients Psychiatric Serv Amercian Psychiatric Association April 2009 60:534-537

What different organic causes can you think of for the following mental health presentations?

DepressionFatigue, insomnia, concentration difficulties, weight loss/gain…

AnxietyChest tightness, breathlessness, palpitations, tremor…

PsychosisHallucinations, delusions, personality changes…

Group Work

Depression: possible organic causes1

• Anaemia• Endocrine – hypo/ hyperthyroidism and diabetes/ (more

rarely) adrenal disease - Addison’s or Cushing’s disease• Alcohol / drug use – cannabis/heroin• HIV/AIDs (consider testing if in high risk group)• Malignancy (more commonly oropharyngeal, pancreatic,

breast and lung cancers)2

• Medications – steriods, beta-blockers, calcium channel blockers, hypnotics, anticonvulsants….

• Neurological condition (especially in older patients) e.g. Parkinson’s or Dementia or even CVA

• Connective tissue disease e.g. SLE (rare)

1 mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings WHO 2010 p23

2 Massie, J Prevalence of Depression in Patients With Cancer Oxford Journals JNCI, VOl 2004, Issue 32, p. 57-71

Anxiety: possible organic causes1

Chest tightnessAngina/MIAsthma

BreathlessnessPE, COPD, asthma, heart failure, mitral valve disease, pneumothorax

TremorHyperthyroidism, underlying neurological disorder – Parkinson’s disease, MS…

Other organic causesDrugs – antidepressants (SSRI – esp citalopram), stimulants Pheochromocytoma – palpitations, tachycardia, hypertension or orthostatic hypotension, N&V and epigastric painRabies – painful laryngeal spasms/dysphagia

http://www.wrongdiagnosis.com/symptoms/anxiety/book-causes-5d.htm [website accessed on 2.1.10]

Psychosis: possible organic causes1

• Infection – cerebral malaria/ sepsis/encephalitis/ meningitis/ HIV/AIDS

• Alcohol/ drugs withdrawal (heroin, marijuana)• Neurological – stroke/ dementia/ Huntington’s chorea• Diabetes (especially hypoglycaemia)• Electrolyte imbalance (hypo/hypercalcaemia,

hyponatraemia, hypomagnesia)• Hepatic encephalopathy• Brain tumour• Medications (e.g. steroids, digoxin, phenytoin,

cimetidine, anticholinergic medications)

1 mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings WHO 2010 p322 http://www.fpnotebook.com/Psych/Psychosis/PsychsDfrntlDgns.htm [website accessed on 3.1.11]

What different physical examinations would you consider in someone presenting with

anxiety symptoms?depressive symptoms?psychotic symptoms?manic symptoms?

General Examination

TemperaturePulseBPHeight and WeightCheck for pallorThyroid swelling?Chronic liver stigmata?Cushingoid appearance?

Endocrine Examination

Thyroid examinationPulse/BPSweaty palms?Tremor?Thyroid gland inspection ?swellingPalpitation ?lump – symmetrical (Grave’s) /nodular (toxic goitre) irregular (cancer) ?tender – thyroiditisCheck for eye signs – proptosis/ exopthalmos/ lid lagPretibial swelling

Munro, JF., Campbell, IW. MaCleod’s Clinical Examination Churchill Livingstone May 2000

Case Scenario of a tired young woman

23 year old woman complained to her GP that she had been feeling tired and low had gained weight recently (she admitted to comfort eating) and had also noticed developing more facial hair.

Her GP organised some blood tests which were as follows:UE: Sodium 130 (135-145 mmol/L)

Potassium 5.0 (3.5- 5.0 mmol/L)Urea 12.0 (2.5-7)Creatinine 90 (60-110)

Random glucose 11.0

What is your differential diagnoses?What is the likely diagnosis?What is your next test to confirm or disprove your diagnosis?

Signs of Cushing’s Disease

Signs of Addison’s Disease

Neurological Examination

Pulse/ BPTremorCranial nerve examination + fundoscopyGaitTonePowerReflexesCoordination

A 73 year old lady comes to you concerned she has a tremor that goes away when she starts eating and is worse when she is under stress and worry. Her husband has also noticed she seems to have difficulty getting out of a chair and feels she has been more withdrawn recently.

What is your differential diagnoses?

What is the likely diagnosis in this lady’s case?

How would you tailor your neurological examination to check for this condition?

Case Scenario – an anxious old lady?

What minimum investigations would be appropriate for someone with depression (e.g. tiredness)?

What is your reasoning?

On what are you basing your reasoning?

Considering Investigations

Case discussion on documentation

Case 1Middle aged man suffering with anxiety. Not eating well and feeling on edge all the time. Travels away a lot on international conferences and feeling stressed with too many lectures to prepare. Felt panicky and heart racing. General examination looked OK. Propranolol prescribed.

Case 2 27 year old doctor feeling low last 3 months with no obvious triggers or past history of depression. Anhedonia and not going out with female friends. Difficulty falling off to sleep and early morning wakening on 5 out of 7 nights – she feels tired most days. Poor appetite and believes has lost 1 stone in weight. Having difficult concentrating on ward rounds which is affecting her performance at work. She denies any suicidal ideation. She doesn’t drink alcohol or use recreational drugs.

On examination poor eye contact, lack of facial expression and slow in speech and movements. Well dressed and kempt. Her pulse 74 reg, BP 150/90mmHg Height 1.65 Weight 52kg (BMI 19.1). No thyroid swelling and no pallor. PHQ score 25/27.

Impression New onset severe depression.

Plan Discussed options – check bloods in view of fatigue and likely weight loss – FBC/UE/TFT/glucose and she is keen to consider medication after bloods – review 1 week

Discuss the 2 different examples of documentation above

Why is good documentation important?

Recording and documentation of findings

SOAP acronymSubjective findings (onset, associated symptoms..)Objective findings (+ve and –ve physical examination

findings)Assessment (working diagnosis with possible

differentials)Plan

Good documentation:Shows good discriminatory thinkingGood evidence for any potential medico-legal casesContinuation of care (colleague sees next time)

Relationship of mental illness to physical health problems

• Depression a prognostic factor for MI (1.8 relative risk)1

and having a MI a risk factor for depression (prevalence 20%)2

• Having moderate to severe depression impacts on post MI survival (relative risk 1.7)3

• Chronic disease and association with depression – cancer (0-58%)/IHD /diabetes (18-28%)4-6

1 Nicholson A. Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies   Eur Heart J (2006) 27 (23): 2763-2774 2 Frasure-Smith N et al. Depression following myocardial infarction. Impact on 6-month survival. JAMA 1993;270(15):1819-25 3 Brett D. et al Prevalence of Depression in Survivors of Acute Myocardial Infarction 4 Review of the Evidence Journal of General Internal MedicineVol 21, Issue 1, Jan 2006 30-31 4 Massie MJ. Prevalence of depression in patients with cancer. Journal Natl Cancer Inst Monogr 2004;(32):57-71 5 Anderson RJ. et al The Prevalence of Comorbid Depression in Adults With Diabetes - A meta-analysis Diabetes Care June 2001 vol. 24 no. 6 1069-1078 6 Van Ede L. et al Prevalence of depression in patients with COPD : a systematic review Thorax 1999 54 p688-692

Depression screening in chronic Illness1

2 screening questions

• During the last month, have you often been bothered by feeling down, depressed or hopeless?

• During the last month, have you often been bothered by having little interest or pleasure in doing things?2

1 Ischaemic Heart Disease/ Diabetes/ Cancer/ chronic pain

2 Nice Guidelines Depression October 2009 p17 [www.nice.org.uk]

Relationship of mental illness to physical health problems

Physical health of schizophrenic patients:• Unhealthy lifestyles• Affect of long term anti-psychotics on their

health – increase rate of obesity, impaired glucose intolerance

Thus schizophrenic patients have higher cardiovascular risk (premature death from IHD)

Cardiovascular Risk Factors and Schizophrenia

Non-modifiable risk factors

Modifiable risk factors

Prevalence inschizophrenia

Gender Obesity1 30–40% (1.5–2 ×)

Family history Smoking2 50–80% (2–3 ×)

Personal history Diabetes3 11–15% (2 ×)

Age Hypertension4 58%

Ethnicity Dyslipidaemia4 45%

1Davidson et al. Aust NZ J Psychiatry. 2001;35:196–202;; 2Herran et al. Schizophr Res. 2000;4:373–381; ; 3Dixon et al. Schizophr Bull. 2000;26:903–912; 4Kato et al. Prim Care Companion J Clin Psychiatry. 2005;7:115–118

BMI = Body Mass IndexAllison et al. J Clin Psychiatry. 1999;60:215–220

Prevalence of Obesity is Increased in Schizophrenia

Normal weight Overweight Obese

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BMI category

Schizophrenia

No schizophrenia

<2020–22

>22–25

>24–26

>26–28

>28–30

>30–33

>33–35>35

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Prevalence of Diabetes in Schizophrenia vs. General Population

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General population

People with schizophrenia

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25–3515–35 35–45 45–55 55–65

Age range (years)

De Hert et al. Clin Pract Epidemiol Mental Health. 2006;2:14n=415 patients with schizophrenia

What do you think should go into a annual health check with someone

with severe mental illness?

Health check on patients with enduring severe mental illness1

General ExaminationBMI (height and weight)- checking for obesitySmokingAlcohol/ drug useBP and pulse checkBlood screening – annual lipids/glucose ?prolactin(esp. if on atypical antipsychotic)

Specific drug monitoring:Lithium – Lithium level 3 monthly, annual TFT/UEAnticonvulsant as mood stabiliser – annual LFT

1 Bipolar affective disorder, severe complex depression, schizophrenia and other long term psychoses

Learning Objectives

• Rationale for physical examination in mental health

• Considering organic causes for different psychiatric presentations

•Tailoring physical examination to different mental health presentations

•Recording and documentation of findings

•Relationship of physical problems to mental health

Identifying Learning Needs

Follow reflective work sheet on learning

2-3 things learnt and how will it change your practice?

What do you want to go and find out more about?

How and where are you going to go to find out this information?