Sunday, October 21, 2007

an octopus in my stomach

Every wednesday, our senior who got an MRCPsych, take us for a session where we discuss a case from a book of PMP (Patient Management Problems), which is written as a preparation for the MRCPsych exam cases....and it is usually very helpful, every thursday we take our ward patient and discuss their management...
Last wednesday it was a really important case were we all fail (i mean all resedent doctor) fail to do the proper management and it was like this, in a summary: a man with a known history of schizophrenia, disorganised type, came to the emergency unit of the general hospital were you work (you means the psychiatrist), saying that there is an angry octopus inside his stomach hitting the walls of the stomach with his 8 legs causing severe pain, and the patient was shouting and aggitated...
I was the first to say with a feling of confidence: somatic hallucinations...
All others resedent doctors agree....but our senior stay silent...we know there is something wrong in our answer...the senior asked me: what would you do? and i was less confedent but I decided to answer: admit him in the ward and start antipsychotics...
Our senior still unsatisfied and little unhappy with my answer asked me to let me rethink: which ward? to which ward you gonna admit him?
I knew that it was clear that I wanted to admit him to the psychiatric ward, but the senior is trying to tell me that am wrong, so I asked the senior, (whome I like and respect very much): sir I don't know what to do else....

He closed the book infront of him and took of his spectacles, took a sigh, and asked me: would like to do something in the emergency room?

I took a deep breath, feeling my failure...

He asked me again: any exam you would like to do?

I thought that he wanted me to exlude a medical condition, and by that the first thing i will think of is confusional state so I answered: a mental state exam to exclude delirium (means confusion) of medical causes....

Our senior asked the others: any one with other Idea?

There was a silence which really made us feel that either we are all (we = resedents) wrong, or our senior is not clear....but hear what he said to us: would you like to do an abdominal exam for him?

We look at each other, I thought in my self this way (an abdominal exam? for what? looking for octopus?)....

I wont bother you by telling you all the details of the rest of the session, but you know what, that man was having a perforated doudenal ulcer presented with acute abdomen, and he was on his way to be in a state of shock from loosing blood, in internal heamorrage, having a history of schizophrenia do not prevent one from having a medical illness.. the problem is that some people with mental illness when present with physical illness they tell the story in a way that is colored by their ideas and delusions and misconception, so that man was percepting the pain in his abdomen as an octopus hitting with his 8 legs the walls of the stomach...

Thanks God that was a lesson not in true life, but from a book, thanks God again and again...we really must take more care...that day I read about medical illnesses in the mentally ill and it is a really long complicated subject, but I will concentrate on it more...here some of my summaries...


Medical comorbidity in psychiatric patients

The psychiatric patients got an unhealthy life style, and 20% shorter life time, (20-40% of schizophrenic commit suicide).
Type II D.M. is 2-4 times more frequent in schizophrenics than in general population.
A study showed that about 20% of schizophrenics between 45-64 years olf got D.M., while non schizophrenics of the same age the prevalence is 5%
Since 1920 scientis found the link between DM and schizophrenia, and since 1950 found that antipsychotic drugs got some diabetogenic effects.
In jasnuary 2004, the amarican associat of DM redefined blood glucose levels:
- normal fastin < or = to 100 mg/dl (not 110)
- diabetic > 126 mg/dl
- 100 -126 is impaired.

Glucose tolerance: after 2 hr. of 75 g must got <> 200 this means DM.

4 comments:

WillBDone said...

That is most definitely a good lesson to learn in a school setting, and thankfully not a real life situation.

I know from personal experience with my mothers illness how difficult it must be for doctors to treat a delusional patient while they happen to also be experiencing other physical problems. It must lead to many scenarios where a patient is improperly treated because they couldn't communicate their symptoms effectively.

May you always execute good judgement and discernment in these difficult cases...

saminkie said...

yeah that is true dear willbdone, and thank you for your care and valuable comments....take care..

Anonymous said...

Dear Dr. El Bedri,
What an excellent lesson to learn. i am glad that it was taught, but i can understand how all of the residents were confused by the situation. Was the senior doctor teaching Dr. Wisam, by any chance? Whether or not it was, please send him my hello, thanks.

Be well, t.

saminkie said...

Dr. Wisam was with us...your hellos always reach him....thank you for your care and take care..am glad to read your comments again...