Case 7- The Case Of Physician Do Not Heal Thyself

Case 7- The Case Of Physician Do Not Heal Thyself

Case #7 The Case of Physician Do Not Heal Thyself presents a case of a 60-year old patient who shows symptoms of complex mood disorder. Moreover, the patient is difficult to handle and uses his medical background to treat himself. Thus, in order to successfully diagnose and manage the condition, the section will examine certain important aspects in the management of such a unique case.

Three Questions

Have you ever had a period in your life whereby you felt that you were different and consequently felt that you were irritable and shouted at other individuals or started fights and arguments?
Has a health professional ever said to you that you are suffering from a complex mood disorder or bipolar?
Has any of your relations ever suffered from any form of complex mood disorder e.g. bipolar?

The rationale for asking these questions involves getting a subjective perspective from the patient. As a starting point, the questions are important as they allow the present nurse practitioner to familiarize herself with the background of the patient before she can conduct a full analysis. In addition, question three may help the nurse identify the genetic makeup of the patient considering that he was not responsive to most of the antipsychotics that he had been given.

People in the Patient’s Life

According to the patient’s social history, he does not have a lot of people that could offer information regarding his status. The closest people that are mentioned are his three divorced wives. However, these are not in his life anymore. Thus, the only people that can be interviewed are his co-workers and friends. His colleagues will thus be asked: “What is his productivity and what does he say about it?” On the other hand, his friends will be requested to answer the question: “How can you describe the interpersonal relationship that he has with you?” These questions are pertinent since they seek to discover if the patient has demonstrated some of the symptoms of complex mood disorder to persons in his social life (Culpepper, 2014). Indeed, the two questions will help reveal the mood of the patient around the people that are in his life.

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Physical Examinations and Diagnostic Tests

A physical examination cannot confirm or discard the presence of complex mood disorder. However, such an examination may succeed in establishing the presence of a medical condition that may cause the existence of the condition’s symptoms. In the present case, the nurse may do a physical examination to establish the presence of either hyperthyroidism or hypothyroidism as they also cause the depressive symptoms that the patient has presented.

In addition to the physicals above, other diagnostic tests may be necessary. Whereas no laboratory test may be required to confirm the presence of the condition, they are important for excluding alternative etiologies for the symptoms shown by the patient (Mann. McGrath, & Roose, 2013). Important in this respect is a urine toxicology and a comprehensive blood count. The former will be utilized to confirm the usage of drugs by the patient whilst the latter test will exclude anemia or infection as the causes of the depressive episodes (Culpepper, 2014).  Moreover, an MRI will be important in excluding an organic etiology for the mood disorder.

Differential Diagnosis

The patient has shown numerous symptoms that make the diagnosis of the disease difficult. The symptoms of the patient indicate the presence of a complex mood disorder. A majority of the said symptoms are shared by other mood disorders. Personality disorders usually mimic or occur concomitantly with complex mood disorders (Culpepper, 2014). The client has demonstrated depressive symptoms that a patient with complex mood disorder is susceptible to having. Also, given the information from the family history in the case study, the patient should be examined for major depressive symptoms. However, the decision to go with complex mood disorder is informed by the presence of irritability and mania episodes that do not reach the thresholds of either hyper- or hypo-mania according to the DSM IV or even ICD 10 tools.

Pharmacologic Agents and their Dosing for the Patient

The patient has not displayed full manic episodes and has similarly not displayed hypomanic episodes. Given his treatment history, it becomes clear that most of the drugs prescribed to him do not work. However, that could be due to the patient’s intransigence as opposed to any scientific basis, with exception of cases wherein specific scientific reasons for discontinuation of an SSRI have been mentioned. Thus, according to the present nurse, the patient should be given either a sertraline (Zoloft) an SSRI or a methylphenidate (Ritalin), a monoamine oxidase inhibitor (Stahl, 2013), which seems to be working for the patient.  The Zoloft will be given in doses starting dose from 50 mg per day. Given the sensitivity of the patient to other SSRIs, this dosage will be increased to a therapeutic range of between 50-200 mg per day. On the other hand, Stahl (2014) states that Ritalin may be given in doses of 20 mg daily. The two agents are chosen for their faster absorption rates and equally fast metabolism once in the system.

Sertraline, which is an SSRI, works by inhibiting the selective reabsorption of serotonin in the brain. Consequently, the chemical elements in the brain responsible for the condition under consideration are balanced as a result. Nevertheless, methylphenidate acts by stimulating the central nervous system.  It does this by inhibiting the reuptake of catecholamines, essentially blocking the reuptake of dopamine and norepinephrine (Stahl, 2013). As a consequence, the concentration of norepinephrine at the synaptic left increases. Thus, from this point of view, the methylphenidate psychopharmacology will be more effective.

Contraindications Based on Ethnicity

Methylphenidate acts by modulating the reabsorption of catecholamines in the brain. As such, the gene responsible for creating dopamine transporter (DART) plays a crucial role in the dosing response of the drug. A study by Froehlich et al. (2011) observed that individuals without copies of the 10 repeat (10R) alleles produced greater remission of the symptoms of the disease due to methylphenidate dose compared to those with the 10R alleles. Given that the 10R alleles are mostly present in Caucasians, Hispanics and African-Americans will experience contraindications from the drug due to its plasms level concentrations. As such, patients from those ethnicities may experience marked anxiety, agitation and tension when given methylphenidate in high doses.

Lessons Learned From This Case Study

The case study of “Physician do not heal thyself”’ has produced important lessons to the nurse. One is that healthcare professionals are in a spot of bother when their prospective client is a colleague in the industry. Such people often display a certain level of arrogance and intransigence when it comes to the prescription of drugs. As such, they need to be incorporated in the decision to formulate an intervention. Also, the case study has revealed that there are certain cases wherein SSRIs do not work but MAOs do. In this case, it becomes important to consider prescribing the MAOs but under very strict observations. Lastly, the case study has accentuated the process that one can use to differentially diagnose mood disorders coupled with personality disorders. The illumination becomes important for future practice as one will use the experience to handle such cases.

Moreover, the present nurse has gained fantastic insights into how to manage the so called difficult clients. According to the case study, the client did not respond to all the medications from his physicians, which compelled him to use his own prescription. Thus, the present nurse will consider listening to self-prescribed patients in future with a view of adopting their ideas in the management of various mental health issues.