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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