History and Physical Write Up
Journal Article
Metacognitive Narrative Psychotherapy
This journal article was in relation to patients with schizophrenia who underwent metacognitive narrative psychotherapy. One my patient presentations revolved around a patient who genuinely believed he was misdiagnosed with schizophrenia and then proceeded to discontinue taking his medication. I wanted to see the effects of psychotherapy if it is effective in transitioning medication non-compliant patients to medication compliant patients. It was a very small sample size, but I believe the results were quite impressive. Over the course of 11-26 months and with an average of ~50 sessions per patient, 8/11 patients significantly improved. The purpose of the trial was to instill a positive outlook the patient self’s image and to associate improved health with medication-compliance. This should give merit for replication of the study but on a much larger scale.
Site evaluation: My summary
I presented a patient who was a 19-year-old, Caucasian, female, domiciled with parents, brought in by EMS activated by the mother, with no known past medical history or past psychiatric history, presented to the ER status post stabbing herself in the neck at approximately 3a.m. this morning. As per patient, her mother was on her way to work approximately 6a.m. where she went to hug her goodbye and quickly realized there was blood on the back of her neck. The mother then called 911. The patient complained of multiple medical complaints that have begun sometimes in January of this year. She has visited various specialists for complaints of weight loss, hair loss, heart issues, thyroid nodules, urinary retention, weakness, pain, and pallor of skin. She explains how difficult it has been these past few months to not have an established diagnosis for her symptoms and how she wished that “all of these doctors could come together to figure out what is wrong.” Patient also explained how her parents have been emotionally abusive, unsupportive, and have been down-playing her symptoms stating it is most likely all in her head. The patient stated her parents would make remarks such as: “There are children with leukemia who are smiling” ultimately further downplaying her symptoms. The patient then complained of a 4-day history of more than usual hopelessness, sadness, helplessness, and depressive symptoms. She denied any SI/HI/AH/VH during that period. Her father texted her last night “something mean” for which she explained was the “breaking point” that caused her to impulsively to take a kitchen knife and stab herself in the neck. Patient was crying multiple times throughout the interview. She was alert and oriented to person, place and time and is in no acute distress. Patient was very slim and appears malnourished. She was cooperative, with pressured speech and anxious. She was noted to be preoccupied with her medical symptoms and the fact that she does not have a diagnosis. It was unclear if the patient may be exaggerating her symptoms. This was a very interesting case presentation. The one differential that appears to come to mind is Somatic Symptom Disorder. Patient has numerous medical complaints, and we are not sure if she is exaggerating them or not. Upon further investigation, the patient had 13 ER visits within the past 2 months which have all been normal. The patient continued to obsess that she had a serious, fatal disease draining her of her life which has impacted her education and function within her family. Patient was then admitted and appears to be a patient who would greatly benefit from psychoeducation/therapy in the attempt to help her understand that her symptoms are not due to an organic cause.
This was my third rotation, so presenting patients has become a little bit easier with each rotation. Dr. Saint Martin is a psychiatrist so he expected the H&Ps to be done and presented in a specific manner that way he could best understand our patients and what the issue at hand was. He gave helpful criticism for everyone and what I had to work on was differential diagnoses. I feel like everyone to some degree struggles with this, because there are just so many disorders, but I just got to think big at first and then try to narrow my differentials down a bit. Sometimes the patient presents with the signs/symptoms of a specific disorder in your head so well and its so hard to try and think of others reason they may be presenting that way. For the future, just need to continuously think about the various mental disorders that could be present, then based on history, narrow it down.
Typhon postings
Self reflection
I had a blast at my psych rotation in the CPEP at QHC. From the patient load to the staff/providers, it was all a great experience. Professor Ali really opened up my mind and sort of changed my viewpoint on the psychiatric field. Many students for sure might think twice about ever working here, but until you witness what goes on and how providers are able to help these patients along with their families, it is a great field to work in. Unfortunately, it was one of my rotations that were only 4 weeks instead of 5 weeks long. Psychiatric conditions are very difficult to picture in your head while studying, so being able to physically see how these patients present, further solidifies the information in your head.
Exposure to new techniques or treatment strategies – how did that go?
Being in the psych ER, one would think there are not techniques utilized other than simple conversation. Working with the attendings and the PAs, you get to see how everyone goes about interviewing a patient and the various techniques used in the interview to try to extract the information you need. Professor Ali would always mention how some of his patients would be very aggressive and he would try to ask them specific questions, that may appear to be unrelated to the situation, but it allows the patient to provide us with details and give us the information that we need. This is something I will try to incorporate with any patient I see.
Types of patients you found challenging in this rotation and what you learned about dealing with them
Patients that I found a little difficult to get a story from were intellectually disabled patients. Although the patient may be 30+ years of age, they may behave as if they were much younger. These types of patients get agitated very quickly and may be trying to attack staff and personal if they are not careful. Most of these patients’ treatment plan relies heavily on the collateral information obtained from the home/parents/etc. Lots of the time I was making phone calls trying to investigate the situation and determine what went wrong. Once we have this information we can then speak to the patient again and go from there.
How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc).
My perspective about psych patients in general has changed a lot because of this rotation. I had an image of what psychiatric patients may behave like based on power-point slides, videos, etc, but until you talk to one and observe how they behave and interact with you it is a totally different scenario. Not all psych patients are severely affected to the point where everyone needs an inpatient stay for 2 weeks + on the psych floor. Lots of patients are depressed, adjusting to specific life events, or even abusing lots of drugs. In the ER setting, we were there trying to determine if they the patient was an acute threat to themselves/others. I would say about 50% of patients that we saw would simply stay the night in the CPEP and leave the next morning feeling a lot better. We would have frequent flyers and patients requesting a medication refill, but the psych ER is not a place where we keep patients for weeks at a time and drug them up to the point, they do not know what they are saying. This is all in the movies.
What one thing would you want the preceptor or other colleagues to notice about your work in this rotation?
I want my preceptor/colleagues to notice that I tend to pick things up quickly. Coming from the medical ER in my prior rotation and now to the CPEP, it felt as if my history taking skills have all vanished. After a couple of consults and initial evaluations of patients with the attendings/PA, I quickly things up and was then able to ask the same questions and try to extract any pertinent information from the patients that may better help us with their management plan. Even though it was a rotation I was hesitant about, I think my classmates saw that I was soon enjoying the interactions with patients along with writing the PES notes. The best part was seeing patients completely stabilize by the next morning after staying a night or two in the CPEP. Many patients tend to benefit from the CPEP which made me want to help out and learn as much as possible.
