The Case of Physician Do Not Heal Thyself
‘The Case of Physician Do Not Heal Thyself’ concerns a 60-year-old patient suffering from a complex mood disorder. The case presents a very complex scenario given that the patient tries to treat himself as a result of his medical background. Self-medication has proven to be very troublesome even with the highest qualified medical practitioners. For effective diagnosis and management of this patient’s mental condition, this paper will examine crucial aspects necessary in developing the most efficacious care plan for such a complex mood disorder.
Three Questions
- Is there any point in your life where you were so irritated to the point that you started arguing and shouting at others, or even fighting with them for no particular reason?
- Have you ever been diagnosed with bipolar or a complex mood disorder previously by a qualified health practitioner?
- Are you aware of any of your relatives who have ever been diagnosed with a complex mental disorder such as bipolar?
The rationale behind the above questions is to get a subjective perspective of the patient’s presenting illness. The questions set a starting ground for the assigned nurse practitioner to be able to understand the background of the patients’ mental condition, and his knowledge of the disorder before conducting a thorough analysis (In Charney, In Buxbaum, In Sklar, & In Nestler, 2014). For instance, the first question allows the nurse to be aware of the effect of the patient’s mental condition to others. The second question gives the nurse an overview of the patient’s past medical history while the last question allows the nurse to understand the family medical history of the patient, given that the patient was unresponsive to previously prescribed antipsychotics.
People in the Patient’s Life
Based on the information provided concerning the patient’s social history, very few people seem to be aware or
concerned with his mental condition. The only people who were close to the patient were his three divorced wives, who unfortunately are not part of his present life. In that case, only his friends and co-workers can be interviewed concerning his mental state and behavior. For instance, his workmates can be asked questions such as “How does he conduct himself around the workplace? Is he productive? How does he feel about his contribution?” Further, his friends will be able to provide information regarding his social behaviors and interpersonal relationships. They can be required to respond to questions such as: “How can you describe him as a friend, in terms of how his communication skills, and even general attitude?” Answers to these questions will help the nurse find out if the people around him have been able to notice presenting symptoms of a complex mood disorder in the patient, and how these symptoms are affecting both his social and professional life (Malgaroli, Maccallum, & Bonanno, 2018). With more questions, the nurse will be able to fully understand the level of mood instability that the patient has and come up with the most effective intervention.
Physical Examinations and Diagnostic Tests
The diagnosis of a complex mood disorder cannot be affirmed or disputed purely by conducting a physical examination. Nonetheless, certain physical examinations can be used to assess related health conditions that might have contributed to the symptoms of mood instability that the patient is experiencing. The thyroid gland plays a significant role in stabilizing the mood of an individual (In Charney, In Buxbaum, In Sklar, & In Nestler, 2014). Hence, the nurse can conduct physical examinations that can enable her to check for hyperthyroidism or hypothyroidism to rule out some of the speculated causes of the patient’s mental disorder.
Other diagnostics tests, such as tests for vitamin disorders, may also be crucial for the diagnosis of the patient’s mental disorder. In as much as lab tests might not seem to be necessary in this case, they are important in ruling out some etiological factors related to the patient’s mental status such as drug-induced mood disorder (Suda, Tatsuzawa, Mogi, & Yoshino, 2017). Additional tests include complete blood count and urinalysis, especially in assessing any toxicities in the patient’s body that might have been caused by the previously used drugs. Imaging tests such as MRI are also crucial in ruling out anatomical aspects of the patient’s mental state.
Differential Diagnosis
The symptoms presented by the patient are similar to several other health complications making the diagnosis very challenging. However, with proper diagnosis, the patient’s symptoms and history point towards a complex mood disorder. Most of the mentioned patients’ symptoms are shared by several mood disorders and depression, which are very much identical to other medical causes. Mental complications such as dysthymia, adjustment disorder with depressed mood, bereavement, bipolar and mood disorder secondary to a medical cause all share the same symptoms (In Charney, In Buxbaum, In Sklar, & In Nestler, 2014). However, from the information provided concerning the patient’s family history, in addition to the DSM IV or even ICD 10 tools, the patient can be confirmed to be suffering from a complex mood disorder, given that the presence of irritability and mania episodes, which do not reach the thresholds of both hyper- and hypo-mania, rules out other differential diagnosis.
Pharmacologic Agents and their Dosing for the Patient
The manic levels of the patient can neither be related to hyper mania nor hypomania. Based on his past medical history, most of the previously prescribed antipsychotic agents were unresponsive to the patient’s mental condition. Most of the time, this is usually as a result of the patient being a defaulter or failing to take the medication as required. Unless a scientific reason is given, the patient should not be stopped from using SSRIs as mentioned. From the perspective of the present nurse in charge of the patient care plan, the options available are either sertraline (Zoloft) which is an SSRI or methylphenidate (Ritalin) which belongs to the broad class of monoamine oxidase inhibitor (MAOI), both of which are effective for the patient current mental condition. The patient will be stated on a 50mg daily dose of Zoloft. With time, the 50 mg Zoloft daily dose will be increased gradually to a maximum dose 200mg given the high sensitivity of the patient to other SSRIs probably due to his genetic make-up (Hough et al., 2017). Consequently, Ritalin can also be given in 20 mg daily dose. The main reason behind the choice of the two pharmacological agents is because of their relatively fast rates of absorption in addition to their rapid metabolic rate once in the body system, hence reduced toxicity.
The mode of action of Sertraline is by selectively inhibiting the reabsorption of serotonin in the brain. Thus, the levels of serotonin in the patient brain will be returned to normal levels hence enhancing mood stability (Hough et al., 2017). Methylphenidate, on the other hand, acts as a stimulant to the central nervous system (CNS) by blocking the catecholamine reuptake system, especially dopamine and norepinephrine, downgrading their high levels in the brain (Dolder et al., 2018). However, the norepinephrine concentration in the synaptic cleft will increase, helping in stabilizing the patient’s mood, hence making methylphenidate more effective.
Contraindications Based on Ethnicity
The mode of action of Methylphenidate is by modulating the levels of catecholamine in the brain through inhibiting their reuptake. In that case, the dosing regulations depend on the genetic composition responsible for synthesizing dopamine transporters (DART). Many studies confirmed that most patients with copies of the 10 repeat (10R) alleles tend to have poor responsiveness to methylphenidate as compared to those without the 10R alleles (Shora, Zarate, Park, & Afanador, 2018). As such, Pena et al. (2017) posit that individuals with the 10R alleles, who are mostly of Caucasians, Hispanics, and African-American origin, are contraindicated from using methylphenidate given its high plasma concentrations that can lead to toxic levels. Additionally, it has been observed that when patients form these ethnicities consume methylphenidate, they display symptoms such as extreme agitation, tension, and anxiety.
Lessons Learned from This Case Study
Nurses can learn several things from this case study of “Physician do not heal thyself.”’ For instance, it is very complicated to treat a patient who is your colleague member of staff, especially when you are working in the same field. Most of the time, they display some level of arrogance to prove their knowledge especially when it comes to drug prescription. To be able to manage such a patient properly, the nurse must be able to find a way of incorporating them in formulating appropriate interventions, so that they might not feel ignored or belittled. Additionally, several aspects of how to choose between SSRIs and MAOI has also been revealed from the case study. For instance, MOA inhibitors can only be used under strict considerations. Otherwise, SSRIs should be considered as the first line. Lastly, how one can differentiate between different mental disorders with identical symptoms have also been mentioned in the case study. Nurses should be able to use the experience gained from this case study to handle similar cases in the future to promote health.
Besides, the present has acquired adequate knowledge and skills required to handle ‘difficult clients’ based on her experience with this patient. Since the patient in this case study felt like the drugs that were prescribed by the physician was not working, he decided to alter the prescription by himself. The nurse is thus aware of the importance of this information in coming up with an appropriate intervention in case of such an encounter in the future.
References
Dolder, P. C., Müller, F., Schmid, Y., Borgwardt, S. J., & Liechti, M. E. (2018). Direct comparison of the acute subjective, emotional, autonomic, and endocrine effects of MDMA, methylphenidate, and modafinil in healthy subjects. Psychopharmacology, 235(2), 467–479. https://doi.org/10.1007/s00213-017-4650-5
Hough, C. M., Lindqvist, D., Epel, E. S., Denis, M. S., Reus, V. I., Bersani, F. S., Rosser, R., … Mellon, S. H. (March 01, 2017). Higher serum DHEA concentrations before and after SSRI treatment are associated with remission of major depression. Psychoneuroendocrinology, 77, 122-130.
In Charney, D. S., In Buxbaum, J. D., In Sklar, P. B., & In Nestler, E. J. (2014). Neurobiology of mental illness. New York, NY: Oxford University Press.
Malgaroli, M., Maccallum, F., & Bonanno, G. A. (2018). Symptoms of persistent complex bereavement disorder, depression, and PTSD in a conjugally bereaved sample: a network analysis. Psychological Medicine, 48(14), 2439–2448. https://doi.org/10.1017/S0033291718001769
Peña, I., Peña, I., Peña, J., Kim, H., Shin, C., Han, D., … Cheong, J. (2017). Methylphenidate and Atomoxetine-Responsive Prefrontal Cortical Genetic Overlaps in “Impulsive” SHR/NCrl and Wistar Rats. Behavior Genetics, 47(5), 564–580. https://doi.org/10.1007/s10519-017-9861-3
Shora, L., Zarate, C., Park, L., & Afanador, M. V. (May 01, 2018). F170. Monoamine Oxidase Inhibitor Use in an Adult Patient With Treatment-Resistant Depression. Biological Psychiatry: Supplement, 83, 9.
Suda, T., Tatsuzawa, Y., Mogi, T., & Yoshino, A. (2017). Unraveling complex relationships among dysphoric disorder, localization-related epilepsy, and mood disorders. Epilepsy & Behavior, 75, 1–5. https://doi.org/10.1016/j.yebeh.2017.07.043