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I saw an interesting patient recently who presented to a medical ward with tiredness and an inability to walk. The case made me think firstly about unusual presentations of disorders and secondly the problem of inadequately trained staff doing assessments outside their field of expertise. The patient was in her 40's and had had a gastric bypass operation seven years ago. She complained of bilateral numbness in her upper thighs, forearms and hands; poor concentration and memory; blurred vision; tearfulness and worry that she may have had a stroke. The doctors and nurses on the ward "could not find anything organic" and were more impressed with the "drama" around her behviour when they visited which they used to support their diagnosis of "psychiatric". Blood tests showed a significant macrocytosis, a very low folate and abnormal liver function tests. On interview the most striking thing was her cognitive dysfunction with disorientation in time and place scoring 18 out of 30 on the mini mental state examination. My diagnosis was of an unusual presentation of Wernicke's encephalopathy and the treatment injections of thiamine after blood tests for vitamin B1 and B6.

The second issue was that this patient had been seen by two community mental health nurses two days previously who had discharged her from their service with a diagnosis of mild anxiety and depression - completely missing the point of the referral and the cognitive problems. What to do about this? I wouldn't expect the nurses to diagnose Wernicke's but would expect them to understand the point of the referral (can't discharge this patient) and not to miss the cognitive deficits. What I'm going to do is to provide them with feedback and also talk to the manager of the service about the community team seeing people in hospital and at least discussing the presentation with a liaison psychiatrist.

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