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Ambrose has recovered, so our
work together can begin in earnest. We work by seeing patients in
tandem: Ambrose takes the history and mental state, then I
sometimes interject with some more questions/clarifications and
then we do any necessary physical examination and formulate a care
plan. I was heartened by Ambrose’s basic history taking and mental
state examination skills. We began to work on being a bit more
focused about his line of questioning, always keeping in mind what
he was trying to rule out or rule in. I also began to notice the
tendency here to often prescribe more than one antipsychotic at a
time, with patients often receiving “booster depot injection” doses
of antipsychotic at clinic if they had any psychotic symptoms, even
if they were fully concordant with their oral medications and there
was room to put up their oral doses. There seemed to be a
perception that giving an injection as opposed to a tablet was
somehow more “potent” than oral medication. We had a short
discussion about this in clinic, but i think it is quite an
engrained practice and I made a mental note to cover safer
prescribing practice at one of our formal teaching tutorials which
I will be holding on Wednesday lunchtimes.
After lunch we had to split
up and see patients separately - this is obviously contrary to the
spirit of the project, where everything we do should be with an
MA/nurse to ensure the passing on of knowledge and sustainability
once we are gone. Having said that, it is easy to say that, but
less easy to stick to when the outpatient corridor is heaving with
patients, some of whom have travelled hours to be there, and there
are only two clinicians to get through them. In addition, seeing
all the patients as teaching cases inevitably slows down the pace.
I know that we will be getting more staff in a couple of weeks, and
until then I will just need to try and split my time sensibly
between service provision and teaching.
In my afternoon clinic, I see
a man in his 50s, who is brought in by his sister. He has a long
history of alcohol use, and some 4 days previously he had
apparently been admitted to a medical ward with a
withdrawal-related seizure. His sister brought a letter from the
general hospital, addressed to psychiatry, saying that some time
after admission, the man had become “aggressive, hallucinated and
uncooperative with treatment” and so they had had to discharge him
and could we treat his “psychiatric problem”. The most striking
thing was the man had been sent home with a bag full of all the
medications that his family had bought for him on admission, but
had not been administered, including about 12 glass phials of IV
Thiamine. The man was very ataxic, delirious and had Wernicke’s
encephalopathy. I felt upset at the way the other hospital had
treated (or not treated) him and I spoke to Dr Dzadney for advice;
she was not at all surprised by this type of presentation and she
told me that any form of mental disturbance, even if there is a
clear physical cause, is felt to be the remit of psychiatry and
that we should admit him for treatment, but warn his family that we
could only keep him for a maximum of three weeks and that he might
possibly have irreversible brain damage. We kept him for about a
week and gave him IV thiamine etc and fortunately he made a full
recovery.
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