I’ve been back for a week now. Without anatomy (I passed!), I have copious amounts of free time, which I fill by watching videos on youtube and strolling around the city. It’s wonderful.
We started psych med on Tuesday and have thus far learned about the Mental Status Exam. The examples given in the book are very novelistic (“She seductively sweeps her bangs away from her face….”) and so I present for your amusement a quick game of Guess the Patient.
Patient X is a student (age debatable), about 5’10 and 160 pounds. His facial appearance is marked by distinct pallor, which contrasts sharply with the inky black of his open doublet and dirty socks that fall around his ankles. He enters the room in a distracted fashion, looking around him as though afraid of being followed. The knocking of his knees also suggests fear. As the interviewer rose to greet him, Patient X drews his right hand slowly to his forehead, then extended it in a flowing motion to meet the interviewer’s outstretched hand. He then sank into a chair, where he remained for the duration of the interview.
The patient answers all the interviewer’s questions readily. His speech pattern alternates between slow, monotonous responses and garrulous outbursts. When asked about his mood, he says that he is “very like a whale.” On being asked to explain, he winked at the interviewer but did not elaborate.
He has a full range of affect, although occasionally a question about his family causes a shadow to pass over his face and shuts down his emotional response. This is brief, however. Thought process is circumstantial and tangential; long digression of the death of an older man who played with him as a child and appears to have been a surrogate father figure. Some loosening of associations. Thought content is obsessive, centering on the recent death of his father and his mother’s subsequent remarriage. Grandiose delusions of his “destiny” as the savior of his family and friends. His girlfriend recently broke up with him, an event he attributes to the influence of her father, a friend of his stepfather.
Some evidence of visual and auditory hallucinations, primarily of his father. These hallucinations command him to avenge his father’s death. Admits to passive suicidal ideations (longing for the “sleep of death”) but has not made a plan due to fear of the afterlife he believes to exist. He also shows evidence of homicidal ideation against his mother, stepfather, and girlfriend’s father.
Cognition: fair. Alert and oriented to self; described interviewer as “fishmonger.” Recalls 3/3 objects in two minutes. Digit span 7 forward, 5 reverse. Does not know own age or age of father at death. Frequently confused two childhood friends. Fund of knowledge good on current events, somewhat shaky on chronology and dates of the past. Above average intelligence, reflected in sophisticated vocabulary. Occasionally invents words.
Poor insight. Patient is aware that his friends and family are “concerned” about his recent behavior. He insists that he is “but mad north by northwest.”
Judgment: Patient does not appear to understand the need for treatment. Recommend hospitalization for suicidal and homicidal ideations.
This year’s summer reading is Mountain Beyond Mountains, Tracy Kidder’s biography of Paul Farmer. I’m holding off judgment until I actually receive it (could be a while, given the Fourth of July shipping delays), but it should be an interesting read, if nothing else. I’d like to do international work eventually, and Dr. Farmer’s kind of a Big Deal in the global health arena. It is gratifying to see that idealism can actually work.
Off-White Coat 