The Shakes

The last half of my Psychiatry Clerkship is at a local community hospital in suburban Boston. The biggest difference is that we spend the bulk of our time in an inpatient geriatric psychiatry ward. This is in stark contrast to the Psychiatry Consult Service I was on earlier, in which the patients were hospitalized primarily for a medical or surgical reason. The patients at the community hospital have serious psychiatric problems. My first patient, Leroy, is an elderly African-American man with schizophrenia. To be diagnosed with schizophrenia, a person needs two or more of the following symptoms present for one month:

• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms (like a flat affect, alogia, or avolition)

You'll recall that one of my previous patients, Clive, had what we thought was schizoaffective disorder, which is schizophrenia with the presence of mood symptoms (depression, mania, hypomania).

I perform the chart biopsy on Leroy and it looks as if he's the chronic paranoid type of schizophrenic. He's been admitted to the geriatric psych ward because of a "change in mental status." I'm not sure what that means, but most probably it refers to him becoming difficult in whatever setting he was in previously (nursing home, assisted living, etc), they got tired of it, and booted him into the hospital. He's homeless, though, and has no close family. The internist has noted that Leroy has a fungal infection on his right hand. Currently, he's on fifteen different medications that treat a number of issues, ranging from the infection to psychotic symptoms.

I stride (yeah, right)....nay, I step with trepidation into the ward (it's a 'locked-in' unit, so the patients can't elope) and look for Leroy. One of the nurses points him out to me - Leroy is sitting in the corner, isolating himself from the rest of the patients. I walk up to him and introduce myself, offering my hand. Leroy just looks at me with suspicion, then ten seconds later, offers his hand. The fungal infection is HYOOGE. The skin is flaky white up to his wrist. Every fingernail is discolored (note: that link is unsafe for the queasy and those eating lunch).

To shake or not to shake? In the next 5 milliseconds during which I reach to grasp his hand, I'm thinking to myself: "I can't renege on the handshake, can I? Oh, great, Mike. Way to go." Leroy and I shake hands.

The interview is rather uneventful. Leroy's thought process and speech are highly disorganized, so he perseverates on random topics that have nothing to do with the questions I ask him. Some of his answers are tangential and just take off and float away into the ether. He's hard to follow because he speaks in a monotone mumble, and all I can think at this time is to not touch anything on my person - not my notes, not my pen, not my pants, not anything. I'm holding my hand at my side awkwardly, I'm sure, as it seems to be pining for a scrubbing with soap and hot water.

The goal for Leroy while he's in the ward is to get him to a point where the social worker can find a nursing home that will accept him. He seems to have calmed down, and he seems quite friendly, as schizophrenics go. In the psychiatry texts, schizophrenia is described as an illness that demonstrates the downward drift hypothesis, in which schizophrenics are unable to function in society and hence sink to lower socioeconomic groups. While Clive and Leroy are certainly noticeably different than us "normal people", I can see that they would be able to fend for themselves independently at some level, despite what the textbooks say.

I end the interview, perhaps a little flustered by Leroy's lack of coherence. Perhaps our interaction, though, has stirred him a little, because, as I turn to leave, Leroy calls after me: "Don't forget to wash your hands."