By Stacey Kusterbeck
If ED patients present with a known psychiatric history, diagnostic overshadowing is a serious patient safety and medical/legal concern. “Unfortunately, I have seen cases where patients with a history of psychiatric diagnoses had their complaints rapidly attributed to their psychiatric condition, without consideration of other possibilities,” reports Adrienne Saxton, MD, an ED psychiatrist at Atrium Health.
In one case, a patient was experiencing a stroke, but complaints of weakness were deemed to be conversion disorder, during which the patient experiences physical and sensory problems, such as blindness or seizure-like spells, with no underlying neurologic pathology.
For another patient, new mood swings and personality changes were attributed to a previous diagnosis of mood disorder, when the real cause was a brain tumor. Elsewhere, hallucinations and confusion have been attributed to schizophrenia, but the real cause was medication toxicity resulting from renal impairment. “Brain tumor, seizure, encephalitis, stroke, or delirium are all conditions that can present with various psychiatric symptoms,” warns Saxton, a clinical assistant professor of psychiatry at Wake Forest.
Patients with these life-threatening medical conditions may report mood swings, personality changes, irritability or aggression, depressed mood, anxiety, or trouble concentrating. If appropriate history, physical exam, and diagnostic testing are not completed, medical emergencies can be missed. This is particularly common if physical exam findings are subtle.
“Cardiopulmonary conditions, such as arrhythmia, myocardial infarction, or pulmonary embolism, could be mistaken as severe anxiety or a panic attack,” Saxton explains. Thus, any potentially serious neurological symptom should not be attributed to a psychiatric cause “without completing an adequate history and physical exam, at a minimum,” Saxton adds.
There are several key pieces of especially important documentation:
• An appropriate history to help narrow the differential diagnosis. “I have seen charts that did not explore in detail the timeline of the patient’s complaints, and did not document inquiry about important associated symptoms in patients with psychiatric disorders,” Saxton notes.
• If the history raises concern for a neurological condition, complete a neurological exam. This is important if the patient reports personality changes (e.g., increased impulsivity, overactive sex drive, or agitation — especially if co-occurring with new headaches, coordination or balance problems, weakness or numbness, or vision changes). Consider periodic reduced arousal, especially in combination with shaking movements, bladder incontinence, or tongue biting. Other signs include onset of hallucinations (especially visual) later in life, loss of sensation, vision changes, and loss of balance.
Good documentation of a neurological exam shows the provider was thorough. For example, a brief exam might document only that the patient was alert and oriented to person, place, and time; that the cranial nerves were grossly intact; and that the patient was moving all extremities. Conversely, a detailed exam would include a review of each cranial nerve function individually (or in related groups, such as cranial nerve III, IV, VI for eye movements) and detail the strength in various muscle groups. The provider would document the specific type of sensation that was tested (e.g., pinprick, touch, or vibration), the gait, and the reflexes in upper and lower extremities.
• Negative “red flag” items in the review of systems. EPs might document the patient reported no severe headache; no vision changes; and no trouble with walking, balance, or coordination. “This can support a physician’s decision to not pursue certain imaging or testing,” Saxton says.
For any patient presenting with a possible psychiatric condition, documentation of a proper medical screening exam is “extremely important,” says Timothy C. Gutwald, JD, an attorney at Miller Johnson in Grand Rapids, MI.
Clear documentation on why a particular test or study was not performed provides a medical basis for why the medical screening exam required by EMTALA was adequate, even if it turns out an emergency medical condition was overlooked. The chart should acknowledge the provider considered ordering an MRI, X-ray, ultrasound, or other test, and explain why the test was not ordered. “Even the best medical documentation cannot overcome actual medical negligence,” Gutwald says.
However, contemporaneous explanations by EPs have strengthened the defense of medical malpractice lawsuits. “It prevents the plaintiff’s expert from creating their own explanation as to why a test was not ordered,” Gutwald adds.
Patients with these life-threatening medical conditions may report mood swings, personality changes, irritability or aggression, depressed mood, anxiety, or trouble concentrating. If appropriate history, physical exam, and diagnostic testing are not completed, medical emergencies can be missed. This is particularly common if physical exam findings are subtle.
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