The doorway physical exam: what every psychiatry resident should know

It is often difficult for psychiatry residents to perform physical exams on patients before their admission to the psychiatry ward. For example, the patient may be violent, be situated in the increasingly common “hallway” emergency rooms designed especially for psychiatry patients, or perhaps she might impolitely refuse your attentions.

Fortunately, it is possible to examine patients without having to touch them. In fact, the physical exam, which is often done without any specialized medical equipment, can be performed while standing in the hall and observing the patient through the doorway.

Before proceeding, you may want to stall for time by checking the patient's blood work — finding any abnormalities might justify returning the patient to the care of the emergency room physician. If, in the end, you must admit and examine the patient (but can't manage the latter for the aforementioned reasons), here are some general guidelines for conducting a doorway physical examination.

Vital signs

These have often been completed by the ED nurses. If not, you may request that they take the vitals, as you are quite busy. (Hint: arrange to have the psych nurse page you several times to create the illusion that you are busy.)

Head and neck exam

If there is a bulge in the general neck area, the patient may have severe thyroid enlargement. (If the thyroid is only slightly enlarged, a senior psychiatry resident would unlikely be able to tell.) If you have good eyesight, check that the patient's pupils are equal in size and then flick the light switches on and off to check for reactivity. (Hint: use this procedure with caution, as it may precipitate a seizure.)

Is the patient shouting at you? That's great. It's an excellent opportunity to check her throat. Is the patient spitting at you? Check for blood in the saliva. (Hint: remember to stand well back and use the patient's chart as a shield.)

Chest exam

Examine for a tracheal tug and deviation of the trachea. If the patient is shouting and able to form long sentences, the airway is probably intact. If he insists upon smoking illegally, see if he inhales and exhales fully. Is the chest expansion symmetrical? If the patient is coughing, or if you need more time, order a chest x-ray.

Cardiovascular exam

Check that the nurse felt a pulse. No pulse? Refer back to Emergency.

Abdominal exam

It's rare for a psychiatric illness to present as abdominal disease, so try not to worry about this portion of the exam too much. It helps to check for nausea, vomiting and diarrhea — ED nurses are an invaluable resource — and to note whether the patient is clutching her abdomen in agony. If the patient disrobes (as she may do without request), check for abdominal scars. Bowel sounds may be audible without the benefit of a stethoscope (especially if someone forgot to order a meal while the patient was stuck in Emergency waiting for a bed on the psychiatry ward).

Neurological exam

Are they awake? Pupils can be checked as described above. You may also observe for facial droop and proper articulation of profanity. Observe gait while patient tries to leave AMA. Is he moving all 4 limbs? The strength assessment can be based upon the number of security guards required.

Review of systems

If the patient has been “medically cleared” by Emergency, a full physical assessment has likely been completed and you may wish to refer to that assessment to fill in the blanks of your physical exam. On second thought, “medically cleared” doesn't mean much. It therefore may be a good idea to state that the physical exam will be completed in depth when the patient is more cooperative. (Hint: with any luck, you won't be on call then.)

Disclaimer 1: Although the doorway physical exam is rather comprehensive, it is NOT a substitute for a complete laboratory investigation of blood and urine, ECG, EEG and head-to-toe diagnostic imaging.

Disclaimer 2: This is just a hypothetical guideline. It has not been validated nor shown to be reliable. In fact, the author has personally never been in a situation necessitating the use of a doorway physical exam. Really.