Clinical Reasoning: A 55-Year-Old Man With Odd Behavior and Abnormal Movements

A 55-year-old man with an extensive psychiatric history that included PTSD, anxiety, depression, and schizophrenia treated with quetiapine and trazodone was admitted to the hospital from an assisted living facility (ALF) for subacute-on-chronic failure to thrive and concern for psychosis, with recent worsening ongoing for 6 weeks. He was recently discharged from an outside psychiatric facility, and at the ALF, he demonstrated odd behavior such as eating food off the floor and spitting on staff, in addition to persistent poor intake of fluids, food, and medications because of issues with regurgitation and dysphagia. He had been evaluated by gastroenterology for more than a decade for these issues, in addition to chronically elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT). An extensive workup including CT imaging, esophagogastroduodenoscopy, esophagram, motility study, and a gastric emptying study was largely unremarkable. In the setting of his psychiatric history and reported history of frequently spitting out food, there was concern for a volitional component to his regurgitation.

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