Show notes
Below is the patient case information:
63-year-old white male.
Problem List Bipolar II disorder
Insomnia
Epilepsy (tonic-clonic seizures)
Dyslipidemia/hypertriglyceridemia
Hypertension
Recent weight gain
History of hyponatremia
Diabetes type 2(controlled)
Medications
Clonazepam 2 mg QHS
Risperdal 2 mg twice daily
Carbamazepine 200 mg twice daily
Divalproex DR 500 mg three times daily
Levetiracetam 1000 mg twice daily
Losartan 100 mg daily
HCTZ 25 mg daily
Atorvastatin 40 mg daily
Fenofibrate 48 mg daily
Metformin ER 500 mg twice daily
Vitals:
Blood pressure is currently 144/86 mmHg
Lipids:
LDL-C: 98
Triglycerides: 245 (down from 423 4 months ago)
CMP:
Na+: 133
K+: 4.1
eGFR: 95
All others WNL as well
CBC:
Hgb: 10:1 g/dL
MCV: 73
Ferritin: 17
A1c:
6.9%
Current Appointment
The patient has seen multiple neuro and psych providers over the last year.
The Risperdal and divalproex were for the bipolar II disorder. The patient is experiencing depression symptoms. His family notes that he has also been uncharacteristically aggressive lately and becomes agitated over minor issues. His family has recently noticed that while talking with him, his face is grimacing, his tongue will randomly protrude from his lips, as well as other facial movements.
The clonazepam for insomnia. It helped with insomnia symptoms for a few weeks, but the symptoms are back to pre-treatment baseline. He was taking clonazepam 1 mg 2 hours prior to bed and zopidem 5 mg 30 minutes prior to bedtime. He didn't feel like the zolpidem was working. The clonazepam was increased to 2 mg and the zolpidem was DC'd. He is also complaining of daytime fatigue
He was recently hospitalized due to hyponatremia. The carbamazepine and levetiracetam were for seizure control. However, the patient has experienced multiple seizures per month for at least the last 3 months.
Needs better blood pressure and triglyceride control
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