Psychotherapy

Case study

· Client Information:(7) J,T 26 y male

· Diagnosis: Schizoaffective disorder - GAD

· Current medications: Clozapine 500 mg daily, Lamotrigine 500 mg daily

· Visit Information: CC: “I still hear voices”  

· Treatment Plan: Add Caplypa (Lumateperone) 42 mg daily.

· Notes: Client accompanied by his mother. Mom concerned about client’s lack of sleep and A/H. Client and mom educated on medication options/alternatives. Client has hx of seizures.

26 y old male accompanied by Mom/caregiver. Client is alert and oriented, calm and cooperative. The legal Mom reports the patient “has been staying up all night at least once a week”. Pt reports he is managing well on his meds. “No issues at work. Mom concerened about pt Staying up all night at least once a week. “Previously he would only stay up all night about once a month”. Patient reports he likes to stay up all night sometimes. Mom concerned if it ok for him to not sleep even on his meds. Client has hx of seizure. Mom concerned missing med doses may be the cause of seizures. Mom concerned about pt injuring himself during seizure. “he was banging his head on them floor during his last seizure”. Pt reports having aurora before seizures and knows when he is about to have a seizure. Mom asks pt “what can we do to make you happier’. Mom want pt to take his prescribed Ozempic for his diabetes (DM) and weight loss. Mom and pt Discussed DM medications and weight loss at length. Client is reluctant to take IM DM medication. Client states “ I don’t like needles’. Pt relaxed only opposed to mom suggestion of IM DM medication. Mom tells pt “it is not a shot it is a prick”. Mom asked if there is any medication, he can take to reduce the voices”. Mom and client educated on Pt medication hx and pt maxing out previously prescribed phsych meds. His mom believes current medication regimen has not been effective. Plan: Add Caplypa (Lumateperone) 42 mg daily. Continue psychotherapy.