Discussion Response

Clinical One

37 Years old, Caucasian male, single man who lives with his brother. Fully oriented, normal weight well dressed, adequately groomed, oddly related, abnormal movements, hesitant, no abnormalities observed, exhibiting both motor and vocal tics, pt. engaged very well despite initially expressed reluctance to speak with us. He frequently wrote his responses down, seemingly due to difficulty fluidly expressing himself verbally in the setting of vocal tics. He reported feeling: marvelous” Diagnosed with schizoaffective disorder bipolar type and moderate opioid use disorder, and a psychiatric history notable for multiple inpatient hospitalization. He has denied any history of substance abuse, though he has been treated for substance abuse in the past, which he attributed to drug overdose without intent to harm himself. His medical history is notable for type I diabetes, seizure, aortic stenosis, hypertension, asthma, and self-reported history of TBI. He currently taking Risperdal Consta 50 mg IM Q2weeks, Lamictal 200mg BID, and Trazodone 50mg qhs. He became noncompliant with Risperdal Consta injection in January 2020, and therefore was switched to oral Risperdal. Most recently he has been treated with oral Risperdal 2mg qhs, Lamictal 200 mg twice a day, Benadryl 50mg qhs, and Cogentin 0.5mg qhs, as well as methadone 80 mg daily. Mr 11/1/20, G.I was transferred to Bellevue hospital to optimize treatment of both his psychiatric and medical conditions. He currently exhibits symptoms of active psychosis including ongoing paranoid delusions, internal preoccupation, and odd relatedness. In addition, he has been exhibiting various vocal and motor tics, which have been reportedly increased in frequency/severity over past weeks. Mr. G. I verbally complained of abnormal movements have included oral movements reported to be involuntary. Patient has been prescribed Cogentin and Benadryl.

Diagnoses: Schizoaffective disorder, Bipolar type and Opioid use disorder

Medication: Lamictal 200mg oral BID, Risperidone 2 mg oral qhs, Cogentin 0.5mg qhs, Lantus 22 units sq qhs, Methadone 80 mg daily, Diphenhydramine 50mg oral qhs, Docusate 100 mg two tabs.

Plan:

Increase to Risperdal 3 mg qhs for psychosis as well as hopeful benefit for motor/vocal tics.

-Continue Lamictal 200mg twice a day for mood regulation.

-Continue Benadryl 50mg qhs for insomnia and EPS

-Discontinue Cogentin 0.5mg qhs given patient already given Benadryl

-Monitor for adverse effects of medications including EPS and metabolic syndrome

-Monitor closely for medication compliance.

-Continue to work with patient to build rapport and insight into symptoms/treatment with goal of hopefully switching back to Risperdal Consta IM