SEEING as I'm considering becoming a Consultant Psychiatrist, or at least a Clinical Psychologist, the following piece of correspondence, found on my road this morning, was of interest. And because I want an office job, I thought I'd practice my typing by tapping it in here. NOTE: I changed the names (have YOU ever met a guy named Potishell?) and NO it is not me. Check the mood report. Does that sound like me? No. Also if it was me, they'd probably note an increased rate and production of speech. [Incidentally the mood section does make psychiatry look like a joke; I would rate my mood as 8/10 and yet Binky says I seem "manic".] Here goes:~
Thank you for referring Mr Potishell Pantswell to services and he was seen on the 21.08.12 and I am now writing with my findings and recommendations.
Reason for Referral: Has a history of mental health problems and you have requested a further assessment of his mental health.
Presenting Problem:
Potishell reported that he is feeling well within his mental state, despite experiencing some residual psychotic symptom (sic). He added that he was not quite sure why he had been referred to us and it was more than likely it was suggested that he would need to be linked in with mental health services.
Mental State Examination:
Appearance/Behaviour: A male, with a medium build, from a Black Afro-Caribbean background. He presented as calm, pleasant and engaged well during the assessment with a good rapport and eye contact established.
Speech: Spoke clearly in English with a normal rhythm, rate and tone observed.
Mood: Objectively he appeared stable within his mood. Subjectively he described his mood as okay and he self-scored his mood as 7 out of 10.
Appetite: Okay
Sleep: Expressed that he is experiencing dreams, which at times he finds distressing.
Abnormal Perceptions: Reported that he experiences visual, auditory and tactile hallucinations. He described that he sometimes see's (sic) vivid lines in different colours, hears occasional voices which he ignores and sometimes feels as if someone is touching his chest and he was unable to describe the type of touch. Currently he reported that his symptoms have greatly reduced, however he still experiences some residual psychotic symptoms.
Concentration: Okay
Delusions: Nil
Self Harm/Suicide: Nil
Insight: Good
Drugs/Alcohol:
Has a past 10 year history of crack cocaine, heroin and alcohol dependence. Currently Potishell denied any current alcohol or illicit drug use. [I bet he's lying.]
Police/Forensic:
Was sentenced to 4 years for burglary [naughty boy! What a terrible thing to do!] and is on probation until 2013 and he has to attend probation twice a week. [How dreadful for him.]
Works part time as a domestic cleaner at B&Q.
Finances:
Is in receipt of a part time salary and expressed that he was managing on this salary. [What? In London?? Either he has no interests and cheap taste, or else he's surely working or committing crime on the side.]
Treatment:
Olanzapine 12.5mg daily, which was prescribed 2 years ago.
Summary And Recommendations
A 38 year old male, who is experiencing some residual symptoms of abnormal perceptions in the form of visual and auditory hallucinations. He has currently remained relatively stable on Olanzapine 12.5mg, which was prescribed 2 years ago. Currently there are no risk factors exhibited and No self-harm or suicidal thoughts elicited.
Plan:
1: I discussed his case with Dr Mazooramabakhadan and he recommended that you increase his Olanzapine to 15mg daily.
2: Dr Parper could you refer Potishell to the Neurologist and conduct a full physical health check.
3: Potishell's mental health to be monitored accordingly by primary care services.
4: Potishell has been advised that he can present at our 24-hr walk in service if he is to find himself in a mental health crisis.
