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The Royal College of Psychiatrists Improving the lives of people with mental illness

First day

Groote Schuur Hospital, Cape Town

The imposing Cape Dutch revival facade of Groote Schuur Hospital, Cape Town, made a for a striking contrast to Mulago Hospital, Kampala, where I spent four weeks studying Obstetrics and Gynaecology. Inside, Groote Schuur had much in common with a London hospital, but as I was soon to find out, it was the aetiology of psychiatric presentations to the Emergency and Assessment wards that would be so different to anything I would see at home. I chose Cape Town for my psychiatry elective based on strong recommendations from KCL students in the years above me. Most patients speak English, making in-depth history taking and mental state evaluation possible. High rates of HIV (17.8%) mean HIV encephalopathy, dementia and psychosis are common presentations as well as common mental health problems on a background of HIV. Tik (methamphetamine) is widely abused in the community, resulting in acute psychotic episodes, and hallucinogens are often prescribed by traditional healers (sangomas) for relief.

This breadth of organic psychiatry, in the context of the great socio-political challenges facing a post-apartheid nation made for an irresistible opportunity to learn psychiatry in a brand new context. My first day on the psych wards did not disappoint me. I met a range of warm, friendly and fascinating patients, all with unique stories to tell. One middle-aged gentleman had a twenty-year history of schizophrenia but had recently been diagnosed with Dandy-Walker malformation, with enlargement of the cerebral ventricles and shrinking of the cerebellum. He presented with cognitive deficits and worsening psychosis. The challenge was to discern whether this was an incidental CT finding or an indication of underlying neuropathology explaining his chronic illness. Next, the psychiatrist covering A&E was called to assess a suicidal twenty-year-old girl with learning disability secondary to foetal alcohol syndrome. Typical of the tragic childhood stories of young people from deprived backgrounds in South Africa, she had lost her mother to TB (likely HIV-related) and her father to a road traffic accident and was living in a township with a kindly woman (she was not in contact with her siblings).

This lady had attended mainstream school late (because, after their parents died, her sister forgot to enrol her), but her learning disability was never commented on by teachers or assessed. She became suicidal, she said, after one of her friends stabbed the other and when she reported this to one of their mothers, she was not believed. Attending A&E for this suicide attempt was her first opportunity to access the learning disability and mental health services available, which she had never been aware of before. Finally, I met a lady in her sixties with worsening persecutory delusions and self-neglect who was thought to have had well-controlled chronic paranoid schizophrenia but was now developing vascular dementia, confirmed by MRI. All three cases were fascinating examples of the interface of psychiatry with neurology and general medicine - and, on day one, affirmed to me the importance of the psychiatrist as the doctor, who foremost, must exclude organic pathology before proceeding to treat psychiatrically. After such a rich first day, I can't wait to see what the rest of my elective holds in store!

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About this blog

Roxanne Keynejad


Roxanne Keynejad is a final year graduate entry Medicine student at King's College London, having studied a first degree in Psychology with Philiosophy at the University of Oxford.


She is spending four weeks of her elective studying psychiatry at Groote Schuur and Valkenberg Hospitals, Cape Town, for which she received bursaries from the Royal College of Psychiatrists elective bursary fund and the Institute of Medical Ethics.