Presentations:
- Usually presented due to disruption of functioning including troubles with the law/complication related to the hallucinations.
- Patient seen by close relatives or family to have a strange behaviour.
Who you are:
You are an FY2 doctor in GP clinic.Who your patient is:
Mother is concerned for her son, Michael Smith, aged 40, as he has been behaving strange for 3 weeks. The other day she made an appointment for face-to-face consultation for her son.What is your task:
Talk to him and address his concerns.
Approach
D: Hi Michael, I can see from my notes that your mother had booked this appointment for you, so can you tell me how I can help you?
P: I don’t have any clue why she did that. I am absolutely fine.
D: Oh I see. So Michael let’s find out what the matter is then okay?
P: Okay.
D: I will ask you some questions, they may sound strange, however kindly bear with me, is that okay?
P: Sure Doctor.
Cognition
D: Do you know where you are?
P: I’m at the clinic.
D: Do you know who brought you here?
P: My mother.
Hallucination Questions
D: Sometimes when people go through difficult times in their lives they tend to hear, see or feel things that are not real, have you ever experienced such things?
P: Yes doctor I hear voices—Explore
D: Since when?
P: A few weeks.
D: How many voices do you hear?
P: 2 voices – Male or female?
D: Do you feel that someone is putting thoughts into your head?
P: Yes.
D: Do you feel that someone is taking thoughts out of your head? Or do you feel your thoughts are being voiced aloud? (So that others can hear them).
P: No.
D: Do you feel that someone is plotting against you?
P: Yes.
D: Do you carry anything on you to protect yourself in case things go bad (v. important).
P: Yes, I keep a knife with me (Here it is—patient sometimes shows the weapon or tries to scare you)
D: Michael I can see you’re worried, but you don’t have to fear at all, you’re very safe here, you can hand me the knife please. I will keep it in a safe place and return it to you later. (Pt agrees and
hand the knife to you)
Idea
D: Michael why do you think all this is happening to you?
P: I am a detective and I know about them that’s why.
Rest of MC FAMISH
Mood
D: How are you feeling?
P: I am okay.
D: Do you feel low?
P: No.
Suicide
D: Some people when they go through difficult times in their lives they tend to hurt themselves or hurt others , have you experienced such thoughts ?
P: No.
Impact
D: Do you feel that this has affected your life, daily activity , people around you or your work? (Important in management).
P: I don’t go out much nowadays doctor because of this.
Insight
P: Do you feel that you need our help ?
P: No doctor, I am fine, thank you.
4F Family ? Friends ? Forensic ? Finance?
D: Who do you live with?
P: My mother.
D: How is your relationship with her?
P: Good.
D: Do you have friends?
P: No I don’t.
D: Are you working at the moment Michael?
Pt: I am a detective but on leave now.
D: Is this affecting your work?
P: Yes they are threatening me to stop investigating them.
D: Are you on any benefits?
P: No doctor, I have my savings.
D: Have you ever had any problems with the law?
P: No, I haven’t had any problems so far.
Medical and Mental Health
D: Have you been diagnosed with any medical condition?
P: No.
D: Have you ever had any mental health problems?
P: No.
D: Has anyone in your family been diagnosed with any mental conditions?
P: No.
D: Do you take any regular medications, OTC or herbal remedies?
P: No.
D: Do you have any allergies?
P: No.
D: Do you drink alcohol?
P: No.
D: Any recreational drugs?
P: No.
Provisional Diagnosis: From the information that you have given me, I suspect that you might be suffering from Psychosis. With this condition, usually patients lose touch with reality and they start to
see, hear or feel things that are not real. It happens due to a chemical imbalance in the brain.
If these symptoms persist for a long period of time and all investigations come back normal, it is then called schizophrenia.
P: Okay, but I don’t think this is my case doctor!
D: How about we chat about what I can do for you?
As we are worried about you, we would like to keep you in the hospital for some time to do some blood tests (to rule out medical cause).
One of my colleagues (from the mental health team) will come and talk to you and if need be and we will get you some medications.
(Note This condition can also be due to drug abuse or alcohol abuse)
Management:
- Admit.
- Senior.
- Investigations
- Blood
– Abnormal LFT and macrocytosis to exclude alcohol abuse.
– Serological tests for syphilis.
– Screening for AIDS. - Urine: for drug abuse.
- CT brain: to exclude brain lesions.
- Medications: Antipsychotic medications
– Risperidone.
– Olanzapine. - We will also provide psychological and social support.
- Talk about support system → Family and friends.
- Referral and Psychotherapy and CBT
- Safety netting → Suicide