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A difficult psychiatric patient
  1. Max J Henderson
  1. Department of Old Age Psychiatry, Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK
  1. Dr Henderson

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A 74 year old man was admitted to a psychiatric ward at the request of his community psychiatric nurse. He arrived unaccompanied by either his nurse or his family. The history in the community psychiatric nurse's letter was that the patient's family had been concerned for the past week as he had taken to his bed. They had needed to wash and feed him. He slept a lot. They had alerted the nurse who, having seen the patient at home, arranged for an urgent admission.

 From the old medical notes it was clear the patient had a long psychiatric history dating back 40 years. His initial diagnosis was obsessive-compulsive disorder but the majority of his admissions had been for agitated depression. He had taken at least one overdose in the past. There was a documented history of alcohol abuse, but it was not clear if this was still an issue. More recently he had developed idiopathic Parkinson's disease. Cognitive impairment had been noted on his last admission: computed tomography had showed cerebral atrophy and some small infarcts and he had been started on aspirin. His medication which accompanied him on admission also included paroxetine, lithium, and co-beneldopa (Madopar).

Very little history was available from the patient, who needed to be roused from sleep. He said he felt “terrible” but could not elaborate. He denied any pain. He admitted being sleepy. No clear psychotic features were noted but it was questioned whether or not the patient understood.

Examination of the patient's cardiovascular and respiratory systems was unremarkable as was that of the abdomen. Neurological examination revealed normal cranial nerves. Parkinsonian features were clearly demonstrated with rest tremor and cogwheel rigidity worse on the left. The patient could walk but needed assistance and conclusions about his gait were not drawn. Reflexes were normaland symmetrical—plantars were both downgoing.

Initial results showed a normal haemoglobin, a slightly raised white cell count (12.3 × 109/l), normal urea, creatinine, and electrolytes, normal glucose on BM finger prick testing and normal urine dipstick.

Questions

(1)
What is the diagnosis in this patient and what would you also consider?
(2)
What particular risk factors for this condition were present in this patient?
(3)
How is this condition normally managed?

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