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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 12 of 12. This is the beginning of the thread.
Posted by Cecilia on June 16, 2001, at 4:31:11
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.
Posted by SalArmy4me on June 16, 2001, at 8:10:04
In reply to Pdocs doing physical exams?????????, posted by Cecilia on June 16, 2001, at 4:31:11
If your doctor were to prescribe something like Effexor (which raises blood pressure), I'm sure he would check your BP from time to time. Same thing if you went on MAOI's. Have you any physical problems which might contribute to a lack of effectiveness or danger with certain drugs?
> 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.
Posted by gheld on June 16, 2001, at 9:10:06
In reply to Re: Pdocs » Cecilia, posted by SalArmy4me on June 16, 2001, at 8:10:04
> If your doctor were to prescribe something like Effexor (which raises blood pressure), I'm sure he would check your BP from time to time. Same thing if you went on MAOI's. Have you any physical problems which might contribute to a lack of effectiveness or danger with certain drugs?
>
> > 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.I'll bet the pdoc would refer you to a primary care doc for blood pressure checks or anything else that involves anything but talk. Anybody ever seen any sort of medical equipment in a shrink's office? Having that sort of stuff present could be threatening to a subset of his/her patients; and therefore be counterproductive.
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.
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> 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.
Posted by kazoo on June 17, 2001, at 2:11:00
In reply to Re: Pdocs doing physical exams????????? » Cecilia, posted by Sunnely on June 16, 2001, at 20:16:12
> All psychiatrists are MDs ...
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^I was wondering when someone was going to mention this. All shrinks are MDs first, then need an additional four to six more years to advance to psychiatry, which is in direct proportion to their hourly rate.
My first psychiatrist would always give me a quick exam, checking vital signs, to determine the presence of any organic problems. If none existed, he would then proceed to exam the inorganic ones (he'd always find those!).
Interestingly enough, a psychoanalyst is not an MD at all, but a Doctor of Philosophy (PhD). Strange world we live in. I wonder what the weather's like on Neptune?
kazoo
Posted by Cecilia on June 17, 2001, at 4:01:53
In reply to Pdocs doing physical exams?????????, posted by Cecilia on June 16, 2001, at 4:31:11
I know pdocs are MD`s but frankly It seems like the easiest practice there is, at least in an Outpatient setting. The diagnosis is usually pretty obvious, there are only a limited number of psychiatric drugs, they either work or they don`t. Seems like easy money. I`ve been prescribed virtually every AD there is and maybe my pdoc assumes I see a regular doc for exams, though of course I don`t because like most depressed people living a long life is not exactly a priority of mine.
Posted by stjames on June 17, 2001, at 18:36:13
In reply to Pdocs doing physical exams?????????, posted by Cecilia on June 16, 2001, at 4:31:11
There are no physical exams specific to the conditions Pdocs treat. It would be very expensive for you to pay a pdoc to do a physical exam, as they generally bill at a higher rate. A Pdoc does not keep up with genetalist reading so a primary care doc gives a better and cheaper general exam and consult.
If your Pdoc has a nurse, ask her to take your vitals; weight, height, BP, and pulse. This will not cut into the valuable time you spend with your Pdoc.
James
Posted by Mitchell on June 17, 2001, at 19:47:32
In reply to Pdocs doing physical exams?????????, posted by Cecilia on June 16, 2001, at 4:31:11
The Virtual Naval Hospital offers the following checklist for an examination of mental and neurological status, including an assessment of cranial nerves and cerebellar status. Generalized psychicatric complaints are sometimes secondary to more illusive neurological problems. Discovery of neurological problems involves examination procedures that are not always included in a routine physical examination. Many examinations for neurological problems involve physical tests that are not easily adapted to remote, text-based relationship such as Internet based medical care.
Neuro/Mental Status
http://www.vnh.org/Shipwreck/Shipwreck.html#20Do all 6 components:
1st- Mental Status Exam
Always check this on all patients: Observation is your best tool, These can be assessed without provoking the pt. Observe the following:
Level of consciousness.
Dress, grooming and personal hygiene.
Facial Expression, posture and motor activity.
Thought content: Perceptions, interpretation of external stimulus.
Manner, affect, and mood.
Thought Process: Sequence, logic, coherence, relevance of thought.
Speech and language.
Insight and judgement.If anything does not seem right in the routine MS exam then check these cognitive Functions:
Test for memory (recent, remote)
Test for calculation ability
Test for orientation x3 (person, place, time)
Test for abstract thinking
Test for judgement
Test for general knowledge
Test constructional abilities
Test for new learning ability2nd Cerebellar Functions
Station
Romberg
Pronator sign
Heel to toe walk
Heel to shin drag
Rapid alternating movements (RAM's)
flipping hands on thighs
index finger to thumb DIP
3rd Motor TestingBilaterally check:
Cranial nerves III, IV, V, VI, VII, IX, X, XI, XII
C5 - T1
L4 - S1
Dermatones4th Sensory Testing
Bilaterally check:
Cranial nerves I, II V, VII, IX, X,
C5 - T1
L4 - S1
DermatonesSensory specific tests: Sharp/dull, 2 point discrimination, Temperature, Vibratory, Pain, Light touch, Proprioception, Stereognosis, Graphesthesia
5th Reflex TestingBilaterally check:
Cranial nerves V, IX, X,
Deep Tendon Reflexes:
C5 - Biceps
C6 - Brachioradialis
C7 - Triceps
L4 - Patellar
S1 - Achilles
Superficial reflexes:
Abdominal reflex -upper T7 - T10
-lower T10 - L1Cremasteric reflex
- L1, L2Superficial Anal reflex
- S2, S3, S4Bulbocavernosus reflex
- sacral sparringBabinski sign
- upper motor neuron lesion6th Cranial Nerve Exam
I- Olfactory
Sensory - smellII- Optic
Sensory - Visual Acuity, Peripheral vision by confrontation.-- FundoscopicIII- Oculomotor
Motor - EOM, accommodation.(lateral rectus, superior oblique)IV- Trochlear
Motor - EOM (superior oblique)
V- Trigeminal
Motor- clench teeth (palpate)
Sensory- bilateral 3 sections of face
Reflex- cornealVI- Abducens
Motor- EOM (lateral rectus)VII Facial
Motor- raise eyebrow, frown, smile, puff cheeks, show teeth, shut eyes tightly.
Sensory: taste to anterior of tongueVIII Vestibulocochlear
Sensory- watch tick, rub fingers, weber, rinne.IX/X Vagus/Glossopharyngeal
Motor- Listen to voice, say "AH"
Sensory- Taste to Posterior tongue
Reflex- gagXI Spinal accessory
Motor- Turn head, Shrug shouldersXII Hypoglossal
Motor- stick out tongue
Posted by stjames on June 18, 2001, at 1:51:05
In reply to Re: Pdocs doing physical exams?????????, posted by Mitchell on June 17, 2001, at 19:47:32
> The Virtual Naval Hospital offers the following checklist for an examination of mental and neurological status,
james here....
This describes a standard neurological exam, one that a neurologist or ER Pdoc would do.
James
Posted by Mitchell on June 18, 2001, at 14:52:25
In reply to Pdocs doing physical exams?????????, posted by Cecilia on June 16, 2001, at 4:31:11
Physical examinations are required by law upon admission to some psychiatric hospitals. Kentucky, for example, requires a physical examination within seven days before or 24 hours after admission to a psychiatric hospital.
Physical examinations may be conducted by a physicians assistant, a certified nurse practitioner, a staff physician, a family physician, a neurologist or a psychiatrist. Physical examinations, in a psychiatric setting, explore contraindications and reactions to psychiatric medications, and seek to discover underlying physical and neurological problems that might be the basis of psychiatric complaints. Elements of a psychiatric physical examination can include simple observations, of which the patient might not be aware.
The quality of information developed in a physical examination can reflect individual practices of a clinic or clinical practitioner as well as the expectations of the consumer. Many clinical practitioners often fail to assess data beyond their narrow area of specialization. Without a comprehensive neurological assessment, by staff or by another clinic, a psychatrist might treat psychiatric complaints, but miss underlying neurological deficits that can cause life-long psychiatric complaints.
Posted by Cece on June 20, 2001, at 2:39:03
In reply to Re: Pdocs doing physical exams?????????, posted by Cecilia on June 17, 2001, at 4:01:53
Hi Cecilia (my name also!)-
It sounds like you've maybe had some bad, or callous, treatment from pdocs- and also that your depression is really wearing you down. I know from my own experience that it is really, really hard to keep chasing after the help that you need when you are barely able to deal with life.
But, a good pdoc doesn't have an easy job. They need to keep up on the constant introduction of new meds, be both scientific and intuitive, and be able to hang in there with very unhappy people. From my own experience, I would not say that diagnosis is obvious- my own diagnosis has evolved over time.
There are many kinds of depression, and different people respond in different, sometimes even paradoxical ways to them. Many people (like me) need to take a carefully worked out mix of meds to achieve successful treatment. There are lots and lots of meds that can be useful for affective disorders- not just the standard, commonly known list, and also meds that are not (yet) been "labelled" for psychiatric use. Some cases of depression are now being recognized as bipolar depression, and being treated with a whole new group of drugs (third generation mood stabilizers)
When I had my first depressive breakdown (30 years ago) and checked myself into a psych ward, I was given a physical by a psych resident. I remember having nerve relexes tested, but no in depth neurological testing- mostly just a cursory physical. I think that it should have been much more thorough. I think that all specialists get tunnel vision in their own area of expertise.
In the years between then and finding a pdoc who I trusted enough to go through endless med trials with, I repeatedly sought out medical exams on my own- I knew that something was "wrong" with me physically, and all the therapy that I did didn't solve it.
This isn't exactly a reply to your query, but it's intended to share experience and to give you encouragement to push yourself on to get the help that you need. Maybe you need to check out some other pdocs- it doesn't sound like you are feeling real trust for your current one. I went through several pdocs before I found one whose intelligence, expertise, and attitude I trusted.
I wish you well,
Cece
> I know pdocs are MD`s but frankly It seems like the easiest practice there is, at least in an Outpatient setting. The diagnosis is usually pretty obvious, there are only a limited number of psychiatric drugs, they either work or they don`t. Seems like easy money. I`ve been prescribed virtually every AD there is and maybe my pdoc assumes I see a regular doc for exams, though of course I don`t because like most depressed people living a long life is not exactly a priority of mine.
Posted by Sunnely on June 20, 2001, at 20:44:18
In reply to Re: Pdocs doing physical exams?????????, posted by Mitchell on June 18, 2001, at 14:52:25
This requirement is practically a universal mandate everywhere by the JCAHO (Joint Commission on Accreditation of Healthcare Organization) and the HCFA (Health Care Financing Administration). Repeated noncompliance with this requirement may lead to citation or worse, loss of hospital accreditation and funding from Medicaid/Medicare.
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> Physical examinations are required by law upon admission to some psychiatric hospitals. Kentucky, for example, requires a physical examination within seven days before or 24 hours after admission to a psychiatric hospital.
This is the end of the thread.
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