S)
70 y/o male patient with PMH significant for chronic hepatitis, cirrhosis, RA, osteoporosis, delirium, and unspecified psychosis. Current medications include codeine/APAP, omeprazole, KCl, Lasix, Risperidone, lactulose, Rifaximin, loratidine, and sertraline. Pt in for outpatient appt on 01/04/2012 – he was at baseline, but fatigued in the mornings. Relative is requesting dose decrease. Denied delusions/hallucinations at this visit. Clinical pharmacist consulted for continued use of nonformulary risperidone.
70 y/o male patient with PMH significant for chronic hepatitis, cirrhosis, RA, osteoporosis, delirium, and unspecified psychosis. Current medications include codeine/APAP, omeprazole, KCl, Lasix, Risperidone, lactulose, Rifaximin, loratidine, and sertraline. Pt in for outpatient appt on 01/04/2012 – he was at baseline, but fatigued in the mornings. Relative is requesting dose decrease. Denied delusions/hallucinations at this visit. Clinical pharmacist consulted for continued use of nonformulary risperidone.
Previous hospitalizations:
2009: Pt admitted to ED after falling in the shower. He was given 80mg prednisone, and became profoundly agitated (required restraints). His agitation improved, but psychosis emerged. Risperidone started. Prior to D/C, pt’s mental status improved and risperidone dose decreased to 1mg in AM and 2mg at HS with hopes of further decreasing dose in future. Ammonia 95 at this visit.
2010: Pt admitted to hospital d/t being unresponsive. Started Rifaximin by GI, and showed improvement. Gained 20lbs over a few days, mostly responded to Lasix. Pt discharged with rifaximin. Ammonia 180 at this visit.
2011: Pt’s CC was AMS. Found that this was likely d/t pt running out of rifaximin and his constipation. Negative for SBP, ascites, and blood culture x2.
O)
10/23/2011: Glucose 106, SCr 0.77, Alk phos 182 H, AST 49 H, ALT 33, bilirubin 1.9 H
BP range last year: 91/50 to 150/88, Mostly 120s/70s.
Pt did not get lipids done during last visit and has not been updated since 2009.
10/23/2011: Glucose 106, SCr 0.77, Alk phos 182 H, AST 49 H, ALT 33, bilirubin 1.9 H
BP range last year: 91/50 to 150/88, Mostly 120s/70s.
Pt did not get lipids done during last visit and has not been updated since 2009.
A)
1. Mental health sx may be d/t hepatic related encephalopathy. Pt has never tried rifaximin alone without risperidone. Also, pt’s 2011 admit for AMS was d/t running out of rifaximin – this may be the medication that is alleviating MH sx.
1. Mental health sx may be d/t hepatic related encephalopathy. Pt has never tried rifaximin alone without risperidone. Also, pt’s 2011 admit for AMS was d/t running out of rifaximin – this may be the medication that is alleviating MH sx.
2. March 2011 MH note states: “Pt appears to have dementia and Parkinson-related symptoms.” Dementa-related psychosis is a black box warning for risperidone d/t increased mortality risk in elderly dementia pts – most deaths d/t CV or infectious events. Also, Parkinson-related symptoms may be d/t risperidone.
P)
1. D/C risperidone – rifaximin alone may be controlling his MH sx, and risperidone has a black box warning for dementia-related psychosis.
2. F/U lipids, since risperidone is associated with metabolic syndrome and can elevate cholesterol.
1. D/C risperidone – rifaximin alone may be controlling his MH sx, and risperidone has a black box warning for dementia-related psychosis.
2. F/U lipids, since risperidone is associated with metabolic syndrome and can elevate cholesterol.
For mental health patients – it’s so important to look at when the start date of the medication was, and see why it was started, and what the situation was. This is a great example of why.
Short post today - getting prepared for residency interviews...first one in San Diego tomorrow!
Short post today - getting prepared for residency interviews...first one in San Diego tomorrow!
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