Limits to the "Medical Clearance" of Patients Presenting With Psychiatric Changes: A Case Report and Review of the Literature.

We discuss a case of a 54-year-old woman with a history of schizoaffective disorder and Parkinson's disease who presented with altered mental status, including weakness, falls, medication refusal, and paranoia, heralding medical deterioration. The treating teams initially suspected that this presentation was medically driven, and she had multiple admissions to general medicine to look for an "organic" explanation of her clinical status. Despite this, no medical driver was identified, and she was diagnosed with progression of her primary psychiatric disease. After she was "medically cleared" and was admitted to the inpatient psychiatry unit for 10 days, she was found to be medically unstable, with progressive dysphagia and decreased responsiveness. She was then admitted to the intensive care unit (ICU), where was found to have dysphagia, aspiration pneumonia, lung abscess, severe hypernatremia, and associated diabetes insipidus, and ultimately died of her medical illness. This case illustrates important limitations of the "medical clearance" of patients with psychiatric presentations, including limited literature and clinical guidance in this area, and risks of the term "medical clearance" itself, which may inappropriately discourage medical reassessments when indicated. We review practices that can help reduce these risks.