Xxxx Xxxx Dob: 10/18/Yyyy

XXXX XXXX DOB: 10/18/YYYY

Risperdal Case Review

Parameter / Findings / PDF Ref /
First Name / XXXX / 1
Last Name / XXXX
DOB / 10/18/YYYY / 1
Past Medical History & Risk Factors (with medications) / In YYYY: Had episodes of seizures and migraine – Treated with Topamax, (The seizure episodes are not clearly defined)
09/05/YYYY: Headache history
09/12/YYYY: Sleep walking history
In YYYY: Bipolar disorder, anxiety – Treated with Risperidone, Buspirone, Hydroxyzine, Topamax
In YYYY: Meniere’s disease
In YYYY: Fatigue / 32, 87, 86, 90
Smoking history / As on 02/27/YYYY, patient smokes 2 packs of cigarette per day (10 cigarettes) for 2 years. Occasionally consumes alcohol (3 times a month) / 224
Age at the time of Risperdal use / 22 years (Considering YYYY as start date per available records) / 90
Start date of Risperdal / 00/00/YYYY (The exact start date is not known)
*Reviewer’s comment: Per record dated 06/18/YYYY, patient stated that he was on Risperdal from YYYY, but we do not have records to substantiate this. / 90
Risperdal Intake details (with dosage) / 04/27/YYYY – 07/01/YYYY: Risperdal 2 mg half tablet at bed time/0.5 mg/4 mg half tablet at bed time / 51-54, 6-9, 464-465, 415, 431-432, 3-6, 32-35, 249-251, 240-242, 237-238, 233-234, 219-221, 211-213, 193-194, 190-191, 175-176, 124-127, 79-96
Adverse events after Risperdal intake / Erectile dysfunction
*Reviewer’s comment: Above mentioned adverse event was taken from medical history dated 06/18/YYYY. The records pertaining to the office visit for erectile dysfunction and its date of diagnosis is not available for review / 124-127
Date of Diagnosis / Unknown
*Reviewer’s comment: Per visit dated 06/18/YYYY, in medical history it was given that patient had erectile dysfunction for 3 years, but the medical records pertaining to the said hospital encounter is not available for review. / 124-127
Age at the date of diagnosis / Unknown
Other complications / 07/03/YYYY: Atypical seizures disorder (PDF: 464-470)
10/10/YYYY: Self proclaimed/unclear seizure like episodes with headache which could be due to complicated migraine. (PDF: 32-41)
02/11/YYYY: Patient stated that he began having seizures associated with his migraine headaches in about YYYY. (PDF: 151)
03/04/YYYY: Possible seizure due to hypotension (PDF: 216-217) / 464-470, 32-41, 151, 216-217
Concomitant medications / Acetaminophen 650 mg, ALOH/MGOH/SIMTH XTRA strength suspension, Benztropine 1 mg injection, Cetirizine 10 mg, Hydroxyzine 50 mg, Ibuprofen 600 mg, Lorazepam 2 mg/ml injection, Lorazepam 2 mg, Magnesium hydroxide 30 ml, Olanzapine injection, Olanzapine 10 mg, Temazepam 15 mg, Topiramate 100 mg, Buspirone 5 mg, Sulfamethoxazole 800 mg/Trimethoprim 160 mg, Nicotine 21 mg patch, Sumatriptan 6 mg/0.5 ml injection, Meclizine 25 mg, Diphenhydramine 50 mg, Mupirocin 2% gel, Doxycycline 100 mg, Epi-pen 0.3 mg/0.3 ml / 259, 265, 292, 323
Date of discontinuation of Risperdal / Unknown.
*Reviewer’s comment: The last available record was on 10/04/YYYY, and there was no evidence to discontinuation of Risperdal. / 79-96
Treatment Received for adverse event / Not available
Current condition of patient (per last available record) / 10/04/YYYY: Patient called stating he needs his mental health medications refilled. He also stating he is having difficulties with his current class load and is requesting an accomodation letter from his previous Mental Health Provider be written to XXX University addressing his mental health diagnoses and that he needs his course load reduced due to his history of bipolar disorder, borderline personality disorder, and attention deficit disorder. / 70

Patient History

Past Medical History: Bipolar disorder, manic type, borderline personality disorder, Meniere’s disease with right hearing aid, traumatic brain injury, migraines, allergic rhinitis, tobacco use disorder, unilateral sensorineural hearing loss, subjective tinnitus, acute otitis externa, pharyngitis

Past Surgical History: Appendectomy, right knee meniscus repair

Social History: As on 02/27/YYYY, patient smokes 2 packs of cigarette per day (10 cigarettes) for 2 years. Occasionally consumes alcohol (3 times a month)

Family History: Maternal grandmother: Colon cancer

Allergies: Hydrocodone/Acetaminophen tablets, Penicillin, Phenergan, Latex straps, Sertraline, mangos

Detailed Chronology

DATE / PROVIDER / OCCURRENCE/TREATMENT / PDF REF /
04/27/YYYY-06/25/YYYY / ABCD MEDICAL CENTRE / Multiple visits for Post Traumatic Stress Disorder (PTSD), Audiology assessment, Traumatic Brain Injury (TBI), migraine headache, bipolar disorder, borderline personality disorder:
*Reviewer’s comment: These visits have been combined and only significant details pertaining to Risperdal has been elaborate below
Case significant details:
@ 04/27/YYYY: Patient presents following a positive PTSD clinical reminder through Primary Care. Patient had inpatient admission in 2011 following suicide attempt. “Zoloft made me suicidal.” He denies currently consuming Sertraline. Initial assessment include Bipolar disorder, receipt of several psychiatric medications, previous inpatient Psychiatric admissions. Refill of Risperdal was obtained today. (PDF: 51-54)
*Reviewer’s comment: Refill of Risperdal was given in this visit but the exact start date of Risperdal is unknown.
@ 06/20/YYYY-06/25/YYYY: Hospitalized for bipolar disorder, borderline personality disorder. Patient is a 24-year old male history of Bipolar disorder, tobacco use disorder and TBI was admitted for about 5 days following a suicidal attempt by cutting wrist and taking an overdose. Patient was on Risperdal, Topamax, Imitrex and Cetirizine.
Medications on discharge: Antipyrine 5.4/ Benzocaine 1.4% otic solution, Azithromycin 250 mg, Cetrizine 10 mg, Hydroxyzine pamoate 50 mg, Ibuprofen 600 mg, Prazosin 1 mg, Risperidone 2 mg half tablet at bed time, Topiramate 100 mg, Zolpidem 10 mg. (PDF: 6-9) / 51-54, 6-9
07/03/YYYY / EFGH Medical Center
XXXXX, M.D.
XXXXXX, E.D.R.N. / Emergency Department record for seizures:
Triage: Patient arrived with friend states that patient had 3 seizures in past 1.5 hours for approximately 1 minute each, starting seizure. Not a Grand Mal seizure. Patient complaints of feeling tingling and rash and itch just started on both arms.
Current medications: Topamax 300 mg, Hydroxyzine pamoate 50 mg, Risperdal 2 mg
Clinician summary: Patient presents with possible seizure like activity. Witness states patient had 4 episodes of starting off in the distance and becoming unresponsive. States these episodes last 1.5-2 minutes. Patient seems drowsy after episodes. Patient reports that he had a Grand Mal seizure 2 years ago. At this time he has generalized tingling sensation. Reports nausea and 1 episode of vomiting. Complaints of headache to right occipital region.
*Reviewer’s comment: Patient had Grand Mal seizure 2 years ago, but records are not available to substantiate these.
CT head: Normal brain imaging study. No evidence of acute bleed. No evidence of mass lesions or midline shift.
Primary diagnosis: Atypical absence of seizures (Atypical seizure disorder), headache, Meniere’s disease
Plan: Ketorolac injection, Hematology lab ordered, Urinalysis ordered, drug abuse screen ordered.
Disposition: Patient discharged to home at improved condition.
Related records: Discharge instructions / 464-470, 471-473
09/25/YYYY-10/03/YYYY / ABCD MEDICAL CENTRE / Multiple visits for suicidal attempt, Psychiatry treatment, depression with suicidal ideation, mental health assessment, manic type bipolar disorder, earache, borderline personality disorder:
*Reviewer’s comment: After review of these records, only significant details pertaining to Risperdal intake have been captured below.
@ 09/25/YYYY: Patient presents with suicidal ideation with attempt earlier by strangulation. Also reports patient punched fire extinguisher with right hand and has some swelling. Home medications include Hydroxyzine 50 mg, Risperdal 0.5 mg.
Medication orders include Haloperidol 5 mg injection, Hydroxyzine 50 mg, Lorazepam 2 mg injection. (PDF: 415-430)
@ 09/26/YYYY: Transferred to Psychiatric Facility for Psychiatric consultation. Discharge medications include Risperidone 0.5 mg (PDF: 431-433)
@ 09/28/YYYY-10/03/YYYY: Hospitalized for manic type bipolar disorder, borderline personality disorder, earache, depression with suicidal ideation. Current medications include Risperidone 2 mg half tablet at bedtime. Discharged to home in stable condition with discharge medication including Risperidone 2 mg half tablet at bedtime (PDF: 3-6) / 415-430, 431-433, 3-6
10/10/YYYY / ABCD MEDICAL CENTRE
XXXX, M.D. / Neurologic consultation report for evaluation of epilepsy:
Patient reports that since YYYY during basic training he has had episodes he believes to be seizures. He reports that he has been told he loses consciousness and his entire body shakes for about 2 minutes He loses control of bladder and sometimes bowel, no tongue biting. These have occurred with varying frequency, but he states that when he is on the Topamax (Prescribed to him for migraine control) he does not have any episodes and when he misses doses he often has seizures and when he runs out of the Topamax and does not have it for a prolonged period he has seizures multiple times per week.
*Reviewer’s comment: Patient had seizures since YYYY, but the corresponding records for seizures are not available for review.
Current medications include Risperidone 2 mg half tablet at bedtime.
Assessment: Migraine headache, possible complicated migraine, self proclaimed/unclear seizure like episodes with headache which could be due to complicated migraine.
Recommendations: Topamax 25 mg. Increased by 25 mg every 7th day up to 50 mg. Imitrex 50 mg for severe headache. Continue Imitrex injection for abortive symptoms.
Summary: Patient with PTSD and migraines here for evaluation for possible epilepsy. By history his episodes sound concerning for epileptic seizures. He does have some unusual associated symptoms raising the possibility of non-epileptic seizures, and it is possible to have epileptic and non- epileptic events. Will continue the Topamax for prevention of migraine and questionable seizures symptoms and get an EEG. / 32-41
10/18/YYYY-02/27/YYYY / ABCD MEDICAL CENTRE / Multiple Psychiatric visits for mental health:
*Reviewer’s comment: Only significant details pertaining to Risperdal intake has been captured.
@ 10/18/YYYY: Patient says his mood has been stressed, “I feel like everybody hates me”. He says he did better when he had Zolpidem, but had episodes of waking up in sleep. He would like to try it again. He has tried Trazodone and did not work. He also asks about medications for Attention-Deficit Hyperactivity Disorder (ADHD), says he was on Ritalin as a child. Current medications include Risperidone 2 mg half tablet at bedtime. (PDF: 249-253)
@ 12/21/YYYY: Patient says Zolpidem is not working for him currently. Has been on Topiramate for 4 years per his report. Uses Hydroxyzine during the day for anxiety. Taking Risperidone and believes his mood is still irritable and unstable and thinks he needs an increase in this medication. Will increase at this time to 2 mg. He says Buspirone is helpful for his anxiety and feels this is suboptimal and agrees to an increase at this time to 10 mg twice daily. Current medications include Risperidone 2 mg half tablet at bedtime.
Plan: Continue current dose of Topiramate, which patient was prescribed originally for migraine and works as mood stabilizer. Discontinue Zolpidem as it does not work. Increase Risperidone to 2 mg at bed time for mood stabilization. Increase Buspirone to 10 mg for anxiety. (PDF: 240-244)
@ 01/02/YYYY: Current medication refilled Risperidone 4 mg (Half tablet at bed time) (PDF: 237-238)
@ 02/08/YYYY: Patient has been anxious and increase in Buspirone is not helpful. Risperidone is helpful for him. Topiramate is helpful in mood stability and migraine. Finds Hydroxyzine is very beneficial and would like to increase it to 50 mg thrice daily.
Current medications include Risperidone 4 mg half tablet daily at bed time. (PDF: 233-236)
@ 02/11/YYYY: History: Patient first began having migraine headaches after his mild TBI while in basic training in YYYY. He stated that he began having seizures associated with his migraine headaches in about YYYY. He stated that these seizures have occurred only about 4 or 5 times since onset. He stated that people have told him that he has flailed around, has struck his head on the ground, has been “out of it” and not aware of what was happening, and had urinary incontinence. He stated that when he comes out of the seizure he is vomiting, his body is tense and tingly, and his muscles feel as though they are locked up and he can’t move. He stated that the seizures last between 1-2 minutes but his last one about 3 months ago lasted for 30 seconds.
Current medications include Risperidone 4 mg half tablet daily at bed time. (PDF: 151, 234)
@ 02/27/YYYY: Active medications include Risperidone 4 mg half tablet daily at bed time (PDF: 219-221) / 249-253, 240-244, 237-238, 233-236, 151, 234, 219-221
03/04/YYYY / ABCD MEDICAL CENTRE
XXXX, M.D. / Emergency Room (ER) record for seizure:
Patient was brought into ER after report of possible seizure 1 hour ago. He reports his head is hurting and he is feeling dizzy, complaints weakness and lightheadedness.
Objective: No significant orthostatic change in his systolic blood pressure.
Current medication includes Risperidone 4 mg half tablet daily at bed time
Assessment: Dizziness/hypotension
Plan: Intravenous fluids started. Patient received 2 liters of normal saline. Advised him to get up from the bed slowly from lying to sitting or from sitting to standing position. Continue Meclizine.
Remained stable while in ER. Discharged to home.
Related records: Medication reconciliation record / 216-217, 211-213
05/09/YYYY-06/03/YYYY / ABCD MEDICAL CENTRE / Multiple Psychiatric visits for mental health:
*Reviewer’s comment Only significant details pertaining to Risperdal intake has been captured.
@ 05/09/YYYY, 05/10/YYYY: Current medication includes Risperidone 4 mg half tablet daily at bed time. (PDF: 193-194, 190-191)
@ 05/31/YYYY: Patient was discharged from military in February YYYY. He reported that he stopped taking medicine for ADHD after he joined military. He reported that he was hospitalized 5-6 times for Psychiatric reasons since YYYY. Reported a history of 5-6 times suicide attempts since he was discharged from military. (PDF: 12-17)
@ 06/03/YYYY: Current medication includes Risperidone 4 mg half tablet daily at bed time. (PDF: 175-176) / 193-194, 190-191, 12-17, 175-176
06/18/YYYY / ABCD MEDICAL CENTRE
XXXX, M.D. / Compensation and Pension (C&P) examination record:
Patient stated that he had to leave his most recent job because he had a seizure related to a migraine and he was asked to resign.
Medical history:
Psychiatric symptoms: Reports taking prescribed Risperidone. Reports treatment for bipolar disorder “and anxiety” started approximately YYYY.
Erectile dysfunction: Not specified. Duration three years. Not TBI related.
*Reviewer’s comment: In this examination, we find a mention of erectile dysfunction. However, we did not find any relevant records pertaining to the past or current treatment for erectile dysfunction. / 124-127
07/01/YYYY / ABCD MEDICAL CENTRE / C&P examination note:
Per C&P examination dated 06/18/YYYY, veteran reported that treatment for bipolar disorder and anxiety begins in YYYY (Medications include Risperidone, Buspirone, Hydroxyzine and Topamax), reported weight gain on medications.
Current medication includes Risperidone 4 mg half tablet daily at bed time.
*Reviewer’s comment: Per record dated 06/18/YYYY, patient stated that he was on Risperdal from YYYY, but we do not have records to substantiate this. / 79-96
10/04/YYYY / ABCD MEDICAL CENTRE
XXXX, R.N. / Telephone conversation:
Patient called stating he does not have appointment for new clinic assignment until November 05, YYYY and he needs his mental health medications refilled. He also stating he is having difficulties with his current class load and is requesting an accomodation letter from his previous Mental Health Provider be written to XXX University addressing his mental health diagnoses and that he needs his course load reduced due to his history of bipolar disorder, borderline personality disorder, and attention deficit disorder.
*Reviewer’s comment: Further records (After 10/04/YYYY) are not available to know the progress of the patient. / 70
07/24/YYYY-12/09/YYYY / Multiple providers / Miscellaneous records: ER record for otitis media, pain assessment, medication reconciliation record, Otolaryngology consultation report, audiology assessment, mental health report, Neurologic assessment record, eye assessment, insurance details, CT head, consent, flow sheet, bipolar disorder assessment, Psychiatric assessment, Cervical spine X-ray, nursing flow sheet, social work sheet, recreational therapy evaluation, immunization flow sheet, home program, case manager note, prosthetic appliance assessment, migraine visit, triage assessment, compensatory work therapy, telephone conversation, Optometry consultation, hearing aids assessment
PDF ref: 363-367, 359-363, 353-354, 354-359, 65-67, 67-69, 61-65, 58-59, 59-61, 55-56, 57, 42-44, 45, 46-47, 48-51, 474-484, 2, 491-502, 29-31, 28-29, 400-414, 434-445, 322-325, 1, 342-344, 347-352, 329-332, 332-333, 313-316, 316-317, 318-320, 387-399, 304-306, 309-312, 294-299, 274-285, 272-273, 253-256, 257, 258-262, 262-271, 246-248, 244-245, 238-240, 26-27, 154-156, 157-159, 159-160, 231-232, 232-233, 230-231, 225-227, 227-230, 218-219, 210, 24-25, 209-210, 25-26, 21-22, 17-19, 19-20, 203-204, 201-202, 10-11, 189, 22-24, 187-188, 174-175, 181-182, 182-183, 167-168, 168-174, 138-146, 161-167, 114-123, 369, 96-114, 70-71, 70, 463, 368, 214-216, 370-373, 204-208, 184-187, 135-137, 72-78, 338-341, 326-329, 344-347, 320-322, 374-382
*Reviewer’s comment: No significant details are noted from above records, hence combined and not elaborated.

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