To get to the original question (medically complicated psychiatric cases), here are two with identifying info taken out:
Middle aged non-English speaking male admitted to an academic medical center for urinary retention of unknown origin. The team decides to keep him overnight. In the evening he becomes agitated and confused with speech becoming largely incomprehensible to the translator. The patient had a history of alcohol withdrawal in the past with unclear substance use history prior to arrival. Team starts ativan plus haldol for agitation. By around 1 AM the patient is restrained and has received high doses of both; an ICU transfer is arranged given his autonomic lability and high nursing requirements / ativan requirements. Psychiatry is consulted.
On initial eval the patient is hypertensive, tachycardic, mildly tremulous and diaphoretic. Exam shows no cogwheeling or dystonia. He is afebrile; medical workup including basic labs and CXR shows no obvious source for delirium. Other studies per ICU team pending. The overnight resident laid out a benzodiazepine regimen for presumed alcohol withdrawal and coordinated with the team on further medical workup.
Day two consists of further ativan, haldol, and agitation. On the night of day two the patient becomes progressively more agitated. The team gives high doses of haldol. The next morning the patient is febrile to around 102; no infectious source is yet evident. On exam that morning he is disoriented, speech near incomprehensible, nonrigid, no evidence of extrapyramidal reactions. Later in the morning, however, his temperature continues to climb to a max of around 105 rectal. Per team he also becomes more rigid; autonomic instability persists. We are stat paged to bedside for recs regarding possible NMS. Recommended holding dantrolene plus supportive care with ongoing workup (by our exam less convinced about NMS); over the day the patient defervesced. We gave recs for continued ativan dosing in the setting of intubation in the ICU. Next day the patient self-extubated and appeared somewhat more oriented. Over the subsequent days an ativan taper was arranged and the patient became progressively more oriented; patient revealed drinking approx 15 drinks per day. Engaged the patient in motivational interviewing and arranged for SW consult for consideration of placement in programs; the patient declined believing his alcohol use was not a problem. The patient was discharged approx one week after presentation.
In this case we had to know alcohol withdrawal well, perform careful neuro exams (which were relevant), bring experience with NMS to bear, understand toxidromes (long considerations of what else could have caused the urinary retention on presentation), and work actively with the team; they expected real input on the patient's AMS and would not be content with us standing on the sidelines.
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Next case I will keep a bit shorter. A non-English speaking woman in her early 50s with an approximately one year subacute decline with poor self-care and psychotic symptoms. Her decline had started wtih occasional lapses in memory and odd behaviors and before long progressed to bizzare hallucinations, both auditory and visual, which resulted in the patient harming a family member. At the same time the patient (previously very concerned about appearance) began to neglect her self care with progressively more bizzare behavior and forgetfulness including leaving gas stoves on in the home. She was evaluated by neurologists and psychiatrists several times including some inpatient stays and was a poor treatment responder with a continuing downward march; given her apathy, depressive symptoms, near absent self-care, and gross psychosis she was ultimately transfered from an outside hospital to our psychiatric inpatient unit for consideration of ECT.
On arrival it was apparent that she was cogwheeling, highly parkinsonian, with fluctuating consciousness and inability to perform even basic activities of daily living such as getting up to stool on the toilet. She was on a regimen including antipsychotics and, per previous reports, only seemed to worsen with them. Based on her neurological and cognitive exam (despite her age) we suspected a dementia had been missed. Despite several prior neurological exams (and pushback from the consult resident that this was, in all likelihood, psychiatric given her negative workups in the past and young age) neurology was brought on board, ultimately confirming a diagnosis of corticobasal degeneration. We continued a decrease in her medication regimen with the goal of maximizing quality of life. The family was very grateful to finally have a sense of what was happening. She was ultimately transfered to long term care and over the coming months passed away of complications relating to her end-stage dementia; over this time the correct diagnosis saved her much unnecessary medication and potentially harmful treatment and provided the family a great deal of peace of mind.
I am typing up these cases not to suggest that a non-physician could not have handled them (although medical skills seemed essential in both cases) but to point out that even as an intern I have seen both of these cases and many more like them. If, like vistaril, the most medically complicated decision you have ever made in four years of psychiatric practice is consulting medicine for a cough and fever you have in all likelihood missed significant medical comorbidities (although I believe he must have seen more medically complicated things and, as is his MO, chooses to omit them in order to bash the field).
