Psychiatry Station 2

Setting:

You are an FY2 doctor working in a psychiatry unit. You are required to see the following patient:

Name: Mr James Riley

Mr Riley was diagnosed with paranoid schizophrenia 4 years ago. He has already been trialled on 2 antipsychotics with little effect. Your consultant reviewed him and has advised starting clozapine. Physical examination, ECG, and bloods are normal. James has no other past medical history and no drug allergies.

Tasks:

1. Counsel Mr Riley on initiating treatment with Clozapine.

2. Answer any questions he may have.

You are not required to examine the patient.

Briefing

Diagnosis: Treatment resistant Paranoid schizophrenia diagnosed 4 years ago. Now requiring Clozapine
Patient Name: Mr James Riley. 44 year old male.

Appearance and Behaviour

You are quiet and reserved. Poor eye contact throughout the consultation. You have limited insight into your condition. You seem sceptical as to whether this new medication will work. You have capacity.

Opening statement

“The consultant recommended that I should try a new tablet as my symptoms have worsened recently.”

Information to Give Freely

“I don’t understand why I need to try another tablet. The previous medications have not made any difference so I don’t think that this new tablet will help either.”

Presenting Complaint

Over the last 2 months, you have been hearing voices more frequently. This has been difficult to manage.

History of presenting complaint

You have been hearing voices in your head for many years.
Usually, you are able to ignore the voices but recently they have become overpowering.
These have become more troublesome recently as you can hear multiple voices talking to each other, saying horrible things about you.
The voices don’t tell you to do anything in particular but they critique everything you do.
You don’t know who these voices belong to.

Risk Assessment

Self harm/suicide? - No
Police altercations? - No
Thought of harming others? - No

Past Medical History

Nil else

Drug History

Medications - Previously had Olanzapine at maximal dose, stopped 1 year ago
Medications - Currently on Aripiprazole at maximal dose
Allergies - None

Family History

Nil significant

Social History

Smoking - No
Alcohol - No
Recreational drug use - No

Ideas / Concerns / Expectation

Ideas - If asked, ‘have you heard of clozapine?’ just shake your head in disagreement
Concerns - You are quite reluctant to try a new medication, especially one with lots of side effects.
Expectations - You want to stop hearing the voices as it is making you very unhappy.

Discussion

Ask any questions from the following list that the student hasn’t already covered.

How does it work?

Will it work better than the other medications I take?

Is it a tablet or injection?

Do I have to come for the blood tests?

Will it completely get rid of the voices?

At the end of the consultation, you agree to try the medication.