Pulmonary embolism in a psychiatric patient.

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“Ms. K,” a 30-year-old uninsured Russian-speakingwoman with bipolar disorder, was brought to the emergency department by family members for aggressive behavior and religious preoccupation. She had stopped taking her prescribed olanzapine and valproate a week earlier. Hermedical record showed nine previous psychiatric hospitalizations and a history of hypothyroidism and obesity. Ms. K’s vital signs in the emergency departmentwere initially stable, with the exception of a pulse between 100 and 115. Results of a chemistry panel, liver function tests, and a blood count were normal. A toxicology screen and blood alcohol test were negative. The patient was deemed medically clear and referred to an acute inpatient psychiatric facility. Because no beds were available, she was restrained in her hospital bed with a Posey belt for 2 days before she was transferred, in accordance with emergency department policy. During her stay in the emergency department, she received no medications but became progressively more withdrawn and hypoactive. On admission to the psychiatric facility, Ms. K’s pulse was 112, her blood pressure 106/78 mmHg, her temperature 37.4°C, and her O2 saturation 98%. She exhibited diminished spontaneous movements and goal-directed behavior and required extensive prompting and supervision to walk into the dayroom. On interview, she was unengaged, with poor eye contact andminimal spontaneous speech. She exhibited psychomotor slowing and spent long periods standing still in the central area of the dayroom, staring ahead. She was started on lorazepam, 2 mg t.i.d., for catatonia. She soon began to improve, ambulating to meals and to the dayroom with minimal prompting. On day 3 of her hospital admission, olanzapine and valproate were restarted. On day 7, she spentmost of the day out of bed and requested to bathe. Staff went to check on her and found her collapsed in the shower. No spontaneous breaths or pulse were detected; CPR was performed, but she was pronounced dead. After an autopsy, the coroner reported “a large, nonmalignant mucinous tumor of the left ovary that occupied nearly a third of her abdominal cavity” and “obstructed pelvic veins and lower IVC [inferior vena cava] enough to cause deep vein thrombosis. Her fatal complication was acute massive pulmonary thromboembolism.” Further history from the family revealed that before Ms. K’s psychiatric decompensation, they had brought her to local emergency departments on three occasions recently because of increasing abdominal girth and discomfort. They initially suspected that she was pregnant, but repeated pregnancy tests were negative. Two of the hospitals performed ultrasound examinations and identified a likely benign ovarian mass. Both deemed it nonemergent and instructed the patient to follow up with outpatient gynecologic services, which her family was unable to coordinate.