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Re: Pdocs doing physical exams????????? Cecilia

Posted by Sunnely on June 16, 2001, at 20:16:12

In reply to Pdocs doing physical exams?????????, posted by Cecilia on June 16, 2001, at 4:31:11

Hi Cecilia,

All psychiatrists are MDs or DOs (Doctor of Medicine or Doctor of Osteopathy) and before a degree of MD or DO can be conferred to an individual, he/she should have passed the rigorous requirements in med school years including doing a physical examination (P.E.). Having said that, I also agree with you that there are psychiatrists who are no longer up to par with their P.E. skills.

Type of practice or specialty of the psychiatrists usually determines whether he/she will be involved in doing more P.E. or not. For example, a psychiatrist working in the E.R. or a Psychiatric Emergency Center will definitely do more P.E. on patients seen than a psychoanalyst (psychiatrist) in a clinic.

The type of hospital setting and insurance coverage may also determine who among the psychiatrists will be doing more P.E. than the others. For example, if an individual with adequate health insurance coverage gets admitted to a private psychiatric hospital or the psych ward of a private hospital, that patient most likely will be assigned to an internist (consultant) who will do the P.E. while under the care of the psychiatrist (primary MD). For those individuals who have no health insurance and get hospitalized in say, a county-funded psychiatric hospital, the psychiatrist usually does the P.E. or nurse practitioners (cheaper than internist) are hired to do the P.E. And for the really destitute patients, believe it or not, there are a number of psychiatrists out there working for free in Homeless Clinics in different parts of the country, who not only would treat the patients' psychiatric condition but also any concurrent medical/physical problems, of course, doing the necessary P.E.

Usually a patient seen by a psychiatrist has been referred by his/her family physician. Even if P.E. is not done by the psychiatrist, he/she usually confers with the patient's family physician regarding the physical/medical health of the patient. Of course, when a psychiatrist prescribe a particular psychotropic medication, he/she is expected to know the specific protocol for using that medication. For example, it would be clinically prudent for the psychiatrist (or his/her designee, usually a nurse) to check the patient's sitting and standing blood pressure and pulse and also listen to the heart, before prescribing a tricyclic antidepressant or a MAOI. At least during the titration period of Clozaril treatment (usually the first 2-3 weeks), it would be clinically advisable for the psychiatrist (or his/her designee) to check the patient's sitting and standing blood pressure, pulse, and temperature. Psychiatrist (or his/her designee) must also check the patient's blood pressure during the titration period of Effexor. Lithium is known to cause underactive thyroid. It is therefore clinically advisable for the psychiatrist (or his/her designee) to feel for any thyroid gland enlargement every 6-12 months, aside from the recommended laboratory tests such as thyroid function tests. When quetiapine (Seroquel) was released, the FDA recommended that eye examination be done prior to and every 6 months of treatment (potential for cataract). However, after several hundred thousands prescriptions of Seroquel, not a single report of cataract formation was reported solely attributed to the use of Seroquel. Therefore, eye examination prior to and during Seroquel treatment is usually no longer being done for this particular reason. And let's not forget that the occurrence of tardive dyskinesia (TD) is still a possibility even with the advent of atypical antipsychotics. Therefore, all prescribing psychiatrists (or his/her designee) are required to do the AIMS examination (Abnormal Involuntary Movement Scale) every 6-12 months for patients on antipsychotic drugs, traditional or atypical.

With the increasing case reports of significant weight gain, sugar diabetes, and elevated triglycerides with the use of atypical antipsychotics, it would be clinically advisable for the psychiatrist (or his/her designee) to check the patient's weight, blood pressure, pulse prior to start of the medication and during regular medication visits thereafter, usually every 3 months. Laboratory tests for sugar diabetes and cholesterol/triglycerides should also be done periodically (e.g., every 2-3 months). Geodon has been reported to cause prolonged QTc. Although electrocardiogram (ECG) prior to and during treatment with Geodon is not required, it would be clinically prudent for the psychiatrist (or his/her designee) to listen to the patient's heart, especially if the patient reveals a history of abnormal heart sound or irregular heart beat. If confirmed by heart auscultation (stethoscope), an ECG definitely should be done or a cardiology clearance sought, prior to start of Geodon.

********************************

> Cam mentioned this in the thread on on-line psychiatry-just curious has anyone ever had a pdoc do this- mine certainly has never checked my BP or done any type of physical exam-frankly I suspect that any pdocs more than a few years out of medical school wouldn`t have a clue how to do any hands on care.


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