
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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