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You are a foundation doctor working with the mental health liaison team. You have been asked to come and see a 22 year old man in A&E who has broken his leg jumping from a window. His name is Harry Thema. The nurses are concerned because he has said that “the voices told him to do it”. He has no past medical history and takes no regular medication.

Please take a history from Harry and undertake a mental state examination. Please focus on the mental health circumstances of his fall, rather than the broken leg itself. You will then be asked to discuss the case with the examiner.

You are Harry Thema, a 22 year old man who has broken his leg jumping out a window. The voices in your head told you to do it. You are currently hearing the voices telling you to lie to the medical student: to confabulate and make up ridiculous information to hide your story. You want to tell the truth, but you can’t help but mention random, irrelevant and impossible information.

HPC You have been hearing these voices for about six months now. They used to only speak to you a few times a day but now it is nearly constant. You do not think that you would ever hurt anyone else but if the voices told you to hurt yourself again, you think you might do what they say.

There are about five different voices who speak to you. They are men and women and one of them is a little girl. You do not recognise the voices as belonging to anyone that you know, although one of them has a thick Glaswegian accent. They talk about you in the third person and say things like “he’s a loser” and “he doesn’t have a clue what he’s doing”. Sometimes they just commentate on what you are doing, for example “now he’s putting the milk in his tea, what an idiot, he hasn’t brewed it for long enough.” You know the voices might not be real but they feel so real that you cannot help but listen. The voices seem to come from outside your head.

Sometimes you feel like thoughts are placed in your head and you have to act on them. For example, two weeks ago you had the thought to steal a can of diet coke from the shop.

You do not think that you have felt or smelt anything that wasn’t there. On one occasion you saw a small dog in your living room which just sat in the corner and looked around. You pointed it out to your flatmate who said there wasn’t anything there. You have felt more down recently but you put this down to the voices, who are constantly putting you down. You have never felt particularly high (without drugs). You used to smoke cannabis but managed to stop this, as the voices didn’t like it very much. The voices have been the only thing able to compel you to act more than cannabis.

Your concentration has gotten very poor, which you put down to the fact that voices are distracting you constantly. You recently lost your job at a graphic design company as a result.

You don’t really like to go out much anymore after an occasion when you went to a club and believed that everyone there wanted to kill you. It was terrifying and you are scared to leave the house much after that.

PMH You are normally fit and well and have had no psychiatric problems in the past

FH You are adopted so you don’t know if you have a family history of any illnesses.

DH You take no medication and don’t have any allergies

SH You have used cannabis since the age of 15. Initially you would only smoke it socially but during university you started using it on a daily basis. You quit last year. You used ketamine a few times during university but otherwise have no other illicit drug use. You used to go out and binge drink every Friday night (you would have about 6 pints of lager and a few shots of spirits) but you have not been out in the past month after the incident where you thought everyone wanted to kill you. You smoke ten cigarettes a day.

You live with your flatmate who you don’t know very well. You think they probably think you’re weird because they avoid you a lot and never really seem to be in. You don’t mind, because they once told you that their favourite film was Pearl Harbour, so they must be weird themselves.

You got a job as a graphic designer after university but you were fired three months ago because you couldn’t concentrate and so were missing deadlines.

You’ve lost contact with a lot of your old friends and live far from your family so you don’t have a lot of support socially. You have never been in contact with the police.

ICE You’re getting really worried now because you can’t control the voices and you’ve hurt yourself as a result. You’re scared of what else they might tell you to do – what if they ask you to kill yourself? You want help but you’re not sure how you can get it.

Observe the student take a focussed history from the patient which should include a risk assessment for future self-harm and harm to others. The student should then try and illicit the ICD-10 symptoms for schizophrenia, as well as asking about risk factors (e.g. drug use). Ask the student to present an MSE for the patient. Ask the student to present their differential diagnosis which should include paranoid schizophrenia.

Topics for discussion: - List some positive and negative symptoms of schizophrenia? - What is the ICD-10 criteria for schizophrenia? - List some common risk factors for schizophrenia? - How would you manage this patient? - What complications are you aware of with schizophrenia?