Who you are:
You are an FY2 doctor in Psychiatry.Who your patient is:
Mr. Alex James, 23 years old, brought to the hospital by the police. According to the police, he thinks that he has done something wrong. After police investigations, police found it’s a false claim.What is your task:
Talk to him and address his concerns.
Approach
D: Hi, I’m Dr (name) , are you Alex James?
P: Yes. Patient looks worried → please reassure.
D: I’m here to talk to you and try to help you?
P: Okay
D: I will ask you some questions that may sound strange. However, kindly bear with me, is that okay?
P: OK.
D: You seem a bit agitated? Can you please tell me what happened?
P: The police are after me.
D: No Alex they aren’t, in fact the police are worried about you.
P: I have committed a crime.
D: You have not done anything wrong. They have gone through your records and found nothing wrong.
P: Okay.
D: Alex, let’s see why you are feeling this way and try to get to the bottom of this.
Hx → MC FAMISH but start with questions of cognition + hallucinations.
Cognition
D: Do you know where you are?
P: I’m at the hospital.
D: Do you know who brought you here ?
P: The police.
D: Did the police come and get you or did you go to them ?
P: I went to them.
D: Have you been harmed in anyway?
P: I’m not sure.
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 now.
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 carry a knife on me.
D: Michael I can see you’re worried, but you don’t have any fear at all, you’re very safe here. Can you hand me the knife please? I will keep it in a safe place and return it to you later. (Patient agrees
and hands you the knife)
Ideas
D: Michael why do you think all this is happening to you ?
P: I don’t know.
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 have thoughts of hurting themselves or hurting 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 or do anything 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: I live alone.
D: Any relatives nearby?
P: No.
D: Do you have friends?
P: No I don’t.
D: What you do for your living?
P: I don’t work currently.
D: Are you on any benefits?
P: No doctor, I have my savings.
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 health 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.
Management
Keep the patient in the hospital if presented there, or emergency referral to the hospital if in GP surgery. (It is a skill to be able to convince the patient to be admitted, without getting into conflict or having to use the Mental Health Act to admit them).
- Talk to my senior.
- Investigations for other causes: (all blood: FBS, TFT, LFTL, U&E, KFT, cholesterol, FBC, ESR, CRP)- urine dip and D&A screening- CXR for chest infection. Serology for Syphilis- Antibodies and PCR for HIV + urine test (infections/drug screen) + CT brain for brain lesions
- Specialist/symptomatic: Olanzapine- Risperidone to reduce the symptoms.
- Psychotherapy and CBT
- Call his GP to get background info.
- Take collateral history from family or partner.
Specialist: referral