Case Formulation and Treatment Plan:
Continue paroxetine (paxil) 30mg p.o daily (depression), buspirone 10mg p.o tid (anxiety), prazosin 1mg p.o nightly (nightmares), 750 mg deparkote p.o daily (seizures / mood stabilization).
Start Haldol 5mg p.o daily for psychotic symptoms. The patient is allergic to abilify, and risperidone. The patient is willing to be compliant with Haldol 5mg p.o daily.
The benefit of the medication was reviewed with the patient. Possible side effects / life-threatening side effects of Haldol and her other prescribed medications were reviewed with the patient. Side effects of Haldol include akathisia, tardive dyskinesia, sedation, dizziness, dry mouth, hypotension, neuroleptic malignant syndrome.
The patient was educated against suddenly stopping the medications without professional advice from the provider. The patient was made aware to contact the office immediately with any questions or proceed to the ER with life-threatening side effects. The patient verbalized understanding. The patient was advised to avoid over the counter drugs, illicit drugs without seeking professional advise.
Initiation:
Start Haldol 5mg p.o daily for psychotic symptoms.
Referral:
Therapist: Recommend individual cognitive-behavioral therapy.
Social worker: to determine if the patient qualifies for Partial Hospitalization Program (PHP) or Intensive Outpatient Program (IOP) to encourage adherence to the medications and plan of care, assist with better coping skills, and provide resources to enhance better living.