Carbamazepine question

[psychma]

I have a client that recently started tegretol. I do not know the dose but I should. They have a mood disorder. Yesterday, while the client was driving, they experienced dizziness, slurred speech, and confusion an hour after taking their dose. They had an unsteady gait and vomited for several hours and were sick all day. Psychiatry asked them to go to urgent care. They did and were not told any of the results of their tests or diagnosis and were sent home. Their blood level of tegretol was 13. They found this out later in mychart. Dr Google tells me this is within range but I’m not a doctor and can’t advise them. Psychiatrist left today without getting back to them. I literally did not know what to say except to tell them to go to the ER if they experience these symptoms again. They are much better today according to self report. I didn’t observe anything but a hand tremor. What should I have done more? Client feels upset with healthcare team and is going to stop all tegretol on their own. I advised against making medical decisions without talking to their psychiatrist, but he left for the weekend without getting back to her.

I am worried about this client just stopping the medication.

What could have caused these symptoms? (I’d like to understand in case this person or another client experiences them.

Is there anything more I should have said or done?

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[forchinet121]

Nothing you can do except for telling the patient to talk to their psychiatrist and go to the ER if they have concerning sxs like this again

 

[Celexa]

Can you see all of their labs? Need to rule out hyponatremia if that wasn't done. I would assume they got a bmp if they checked a level but I've also learned not to assume competence.

 

[Celexa]

Also, what is the unit on the level? Could be high or low.

If they recently started the med and have not yet experienced any significant psychiatric benefit, then there is very little risk to stopping it so I wouldn't worry much about that.

 

[psychma]

I don’t have access to their labs. I’m not in epic. I don’t know what else was done.

 

[psychma]

Could this have been some sort of toxic cerebellar event? I know alcoholics can have toxic blood levels of alcohol but be less affected because they’re habituated to it. If someone is medication naive could a standard blood level cause cerebellar toxicity? Warning: I got my medical degree on Google.

 

[wolfvgang22]

Could this have been some sort of toxic cerebellar event? I know alcoholics can have toxic blood levels of alcohol but be less affected because they’re habituated to it. If someone is medication naive could a standard blood level cause cerebellar toxicity? Warning: I got my medical degree on Google.

Unlikely.

 

[Celexa]

I don’t have access to their labs. I’m not in epic. I don’t know what else was done.

Are you a therapist? The key point for you here is that there is a big difference between stopping a long term med that is clearly keeping a patient safe/stable/out of the hospital, and a new med for a patient who isn't in crisis. The former I absolutely do not want a patient to stop without telling me; the latter, it's not a big deal and we can talk at the next visit.

 

[psychma]

Unlikely.

Cerebellar syndrome? I just found a paper. I should be working on documentation.

 

[psychma]

Are you a therapist? The key point for you here is that there is a big difference between stopping a long term med that is clearly keeping a patient safe/stable/out of the hospital, and a new med for a patient who isn't in crisis. The former I absolutely do not want a patient to stop without telling me; the latter, it's not a big deal and we can talk at the next visit.

Yes, I already got that out of this conversation. I’m a therapist. It doesn’t stop me from being curious about this.

 

[psychma]

I had the client in my office not knowing what had happened to them and they were upset and scared. She had no feedback from her healthcare providers. Her story sounded scary as this happened when she was driving. Fortunately, someone was in the car with her. I’m just putting off writing notes wondering myself.

 

[annoyedpsychiatrist]

Blood levels of a medication can be deceiving, as it depends on the time of when it was drawn, the dose they took, etc. If they took a big dose of it and immediately had their level drawn then that wouldnt be an accurate trough level of the medication. It is impossible to say what happened (based on the info presented) ultimately as it could have interacted with another medication, patient experienced side effects to it, or was just a different medical disorder all together causing those symptoms. Depends on a lot of details.

Also im not sure what they're using it for specifically, if its being used for bipolar, seizure disorder, etc. Basically they should always consult the prescribing physician when things like this happens, and if they dont trust their prescribing doctor/get no response, start looking for a different doctor. And no I do not think it was some type of cerebellar event.

 

[mistafab]

I recommend you just double down with what you did. Always recommend they speak with the doctor before making medical decisions. The rest of it is up to the client, not you.

You can never know the full story if you are not there at the time of assessment (like at the urgent care). So I wouldn't read into the tegretol specifically, and I wouldn't jump to any conclusions. For all you know the patient ingested wild berries that caused those same symptoms. Unless you're the treating physician, just punt it.

 

[Candidate2017]

I had the client in my office not knowing what had happened to them and they were upset and scared. She had no feedback from her healthcare providers. Her story sounded scary as this happened when she was driving. Fortunately, someone was in the car with her. I’m just putting off writing notes wondering myself.

First, boundaries are important. This is a basic tenet that many "therapists" don't grasp.

You're not a doctor. There's not much for you to do other than copy the tag line of a drug commercial, "Don't start or stop meds without talking to your doctor" and "Go to the ER if you are experiencing concerning issues." Which you did. There is no need to worry about cerebellar ataxia, Tegretol, or otherwise going beyond your boundaries as a non-physician.

Second, the primary job is therapy. Rather than introjecting the patient's upset and fear, did you use what they brought up as grist for therapy? There are so many things to explore. What does it mean to be on meds? What are their transferences with respect to their psychiatrist? How have they handled distress in the past? What does it mean to not have their psychiatrist get back to them immediately? Did they read the Tegretol package insert from stem to stern? Do they always get side effects from meds? Do they often start and stop meds? What's their relationship to the person in the car? Etc, etc, etc.

What is your formulation for this person beyond "mood disorder"? And, above all, how did this patient's session make you feel?

 

[psychma]

First, boundaries are important. This is a basic tenet that many "therapists" don't grasp.

You're not a doctor. There's not much for you to do other than copy the tag line of a drug commercial, "Don't start or stop meds without talking to your doctor" and "Go to the ER if you are experiencing concerning issues." Which you did. There is no need to worry about cerebellar ataxia, Tegretol, or otherwise going beyond your boundaries as a non-physician.

Second, the primary job is therapy. Rather than introjecting the patient's upset and fear, did you use what they brought up as grist for therapy? There are so many things to explore. What does it mean to be on meds? What are their transferences with respect to their psychiatrist? How have they handled distress in the past? What does it mean to not have their psychiatrist get back to them immediately? Did they read the Tegretol package insert from stem to stern? Do they always get side effects from meds? Do they often start and stop meds? What's their relationship to the person in the car? Etc, etc, etc.

What is your formulation for this person beyond "mood disorder"? And, above all, how did this patient's session make you feel?

No worries. I did my job as a therapist. I was just curious about that type of reaction to a med. yes, it’s out of my field, but I often research things I find interesting. There’s nothing wrong with that. I’m not trying to play doctor. I know my limits professionally and I don’t recommend meds or do anything but refer clients to their psychiatrists. I do a lot of therapeutic work around staying medication compliant. But the dr runs the show. I’m just curious about this weird reaction. I’ve kind of exhausted my search and had a good chat with my friend who is a pharmacist. I moved on to finishing my documentation.