CHAPTER 2 The physical examination and investigations relevant to psychiatry
This chapter provides a brief overview of the physical examination in psychiatry, as well as pointing to special investigations that might be pertinent in the psychiatric setting. Of course the extent of special investigations depends upon the clinical presentation and findings on psychical examination, but as a general guide those investigations shown in Box 2.1 are recommended in most cases.
Why a physical examination?
Many psychological disorders are provoked, amplified or complicated by general physical illness. In addition, some patients present with psychological symptoms due entirely to general physical illness (see Ch 4). It is appropriate to ensure that a comprehensive history and physical examination is included in the management of most patients presenting with psychological disorders. Exceptions to this include patients whose medical history is well known already or who choose to decline such examination (the potential consequences must be explained to the patient and documented).
Sometimes, the examination will need to be postponed until the patient is capable of informed consent. For example, capacity for consent may be impaired by psychosis associated with fear of contact or a history of sexual abuse may provoke anxiety about an examination.
Context of the physical examination
A thorough mental state examination (see Ch 1) will help focus the physical examination, but a brief review of all systems is essential. A good motto is ‘when in doubt, think organic’ and review all physical findings, as some general medical disorders may present with psychological symptoms (see Ch 4).
Elements of the physical examination
Observation
facial expression (e.g. tearfulness, injected conjunctivae from substance abuse, dystonia and dyskinesia with medications, fixed gaze or grimacing in schizophrenia)
