Psychiatry Initial Consult - Detailed

Dear Dr. Smith,

Thank you for your referral request regarding Lucas Bennett, a patient who is currently under your care.

Identification:
Lucas Bennett is a 44-year-old male. He lives independently in the community and is engaged in regular occupational therapy, with ongoing cognitive assessments approximately every three months.

Reason for consultation:
Lucas presents for follow-up regarding ongoing management of mood and cognitive symptoms, including increased fatigue, abnormal appetite, weight gain, persistent cognitive difficulties (notably word-finding issues and irritability), and medication side effects, particularly related to fluoxetine and valproic acid. The primary focus of this consultation is to address medication side effects and to discuss a gradual reduction of valproic acid due to cognitive side effects and lack of efficacy for headaches. There have been no recent incidents of acute psychiatric or neurological deterioration, and no concerns regarding safety or suicidality. The patient is motivated for medication optimization and gradual tapering.

Informants:
Information was obtained from direct telephone interview with Lucas, as well as collateral input from his wife during the consultation.

Relevant medical/psychiatric history:
Lucas has a history of Major Depressive Disorder, ADHD (Inattentive Type), Post-Concussion Syndrome, and Adjustment Disorder with mixed anxiety and depressed mood. He has experienced multiple concussions resulting in post-concussion syndrome and persistent cognitive symptoms. He also has a history of chronic migraines (currently managed with Botox and Ajovy), hypertension, hypercholesterolemia, carpal tunnel syndrome, and vitamin B12 deficiency. Previous adverse reactions to topiramate (kidney stones) and nortriptyline (ineffectiveness for migraines) have been noted. There is no history of suicide attempts or substance use disorder. Lucas is adherent to his prescribed medications and has not reported any issues with administration prior to this encounter.

Past Medical History:
• Multiple concussions and post-concussion syndrome, with persistent cognitive symptoms
• Chronic migraines, managed with Botox and Ajovy
• Hypertension
• Hypercholesterolemia
• Carpal tunnel syndrome
• Vitamin B12 deficiency
• Adverse reaction to topiramate (kidney stones)
• Nortriptyline ineffective for migraines

For each medication, provide the following details in a bullet list format:
• Valproic acid 1000 mg daily (currently transitioning to 750 mg in capsule form and 250 mg in oral solution, with gradual taper as tolerated)
• Nortriptyline 40 mg daily
• Candesartan 100 mg daily
• Pantoprazole
• Rosuvastatin
• Concerta (methylphenidate)
• Fluoxetine 40 mg daily

Lucas has a documented history of Major Depressive Disorder, Attention-Deficit/Hyperactivity Disorder (predominantly inattentive presentation), and Adjustment Disorder with mixed anxiety and depressed mood. He has experienced persistent mood instability, irritability, and cognitive symptoms following multiple concussions. He has been managed with various psychotropic medications, including fluoxetine, nortriptyline, and valproic acid, with variable efficacy and tolerability. There have been no psychiatric hospitalizations. No history of suicide attempts. No significant family psychiatric history. No history of substance use disorder. Lucas has not reported any use of alcohol, tobacco, or illicit substances. There is adherence to prescribed medications, with no significant issues noted aside from the need to coordinate prescription refills and consult with the pharmacist regarding gastrointestinal side effects potentially related to the liquid formulation of valproic acid. No facility-administered medications prior to the encounter.

Current Outpatient Medications on File Prior to Encounter
• Valproic acid 1000 mg daily (to be transitioned to 750 mg in capsule form and 250 mg in oral solution, with gradual taper)
• Nortriptyline 40 mg daily
• Candesartan 100 mg daily
• Pantoprazole
• Rosuvastatin
• Concerta (methylphenidate)
• Fluoxetine 40 mg daily

Allergies:
No known drug allergies reported.

CLINICAL INFORMATION:
Lucas Bennett is a 44-year-old right-handed male with a complex psychiatric and neurological history, including Major Depressive Disorder, ADHD (Inattentive Type), Post-Concussion Syndrome, and Adjustment Disorder. He has a history of multiple concussions, chronic migraines, hypertension, hypercholesterolemia, carpal tunnel syndrome, and vitamin B12 deficiency. He is currently experiencing increased fatigue, abnormal appetite, weight gain, persistent cognitive difficulties, and irritability, particularly in the context of recent medication adjustments and ongoing psychosocial stressors.

INVESTIGATIONS:
• Neurologist correspondence notes ongoing cognitive symptoms but overall neurological stability.
• Regular cognitive assessments are performed by his occupational therapist approximately every three months.
• No acute abnormalities have been identified in recent neurological evaluations.
• No new neuroimaging or laboratory investigations were indicated or performed during this follow-up.

History of presenting illness
Lucas reports increased fatigue, abnormal appetite, and weight gain since his fluoxetine dose was increased to 40 mg daily. These symptoms have been significant enough to impact daily functioning, particularly in terms of energy and weight management. He reports persistent cognitive symptoms, including word-finding difficulties and irritability, and denies current headaches or cognitive instability. Lucas is adherent to his medication regimen and is motivated to reduce valproic acid due to cognitive side effects and lack of efficacy for headaches. He is engaged in regular cognitive monitoring with his occupational therapist. He also reports sleep disturbances, including difficulty initiating and maintaining sleep, and gastrointestinal discomfort (notably nocturnal abdominal pain after taking valproic acid solution, even when administered with food). These symptoms have impacted daily life, including reduced energy, impaired sleep quality, and increased emotional reactivity, which have affected interactions at home and in social settings. There are no recent incidents of acute psychiatric or neurological deterioration. Lucas denies current headaches or cognitive instability. He also reports no adverse effects from fluoxetine for headaches. He is motivated for gradual medication optimization and is adherent to treatment recommendations.

Relevant personal history
Lucas was born in Australia and has a history of multiple concussions resulting in post-concussion syndrome and persistent cognitive symptoms. He has a background of mood instability and ADHD, with ongoing management of chronic migraines. He lives independently and is actively involved in his own care, including regular occupational therapy and cognitive assessments. He is married and his wife provides collateral information regarding his mood and behavioral changes. There is no reported history of substance use disorder or significant family psychiatric history. He is currently facing significant psychosocial stressors, including an impending court case and ongoing legal and administrative challenges, which have contributed to mood lability and anxiety.

Mental status examination

Interview Setting: The review was conducted over telephone. Lucas was cooperative and appropriately engaged during the consultation. His wife was also interviewed for collateral information.

Appearance: Lucas appeared his stated age, was cooperative, and engaged throughout the consultation.

Perception: No hallucinations or perceptual disturbances reported.

Thought Process: Linear, logical, and goal-directed.

Hearing: No hearing difficulties reported.

Eye Contact and Rapport: Not directly assessed due to telephone interview, but rapport was easily established.

Psychomotor Activity: No psychomotor agitation or retardation noted.

Mood and Affect: Lucas reports feeling generally good but tired, with intermittent anxiety and irritability. Affect was congruent with mood, with some tearfulness and emotional lability noted.

Thought Content: No delusions, obsessions, or phobias reported. Lucas denied any current or recent suicidal ideation, intent, or plan, though he acknowledged occasional passive thoughts of death in the context of significant stress, without intent or plan.

Suicidal Ideation: Denies any current or recent suicidal ideation, intent, or plan.

Insight and Judgment: Good insight and judgment regarding medication changes and symptom monitoring.

Impression and recommendations

1. Major Depressive Disorder, Recurrent, Moderate (296.32, F33.1): Ongoing depressive symptoms, currently managed with fluoxetine 40 mg daily. Increased fatigue and abnormal appetite with associated weight gain since dose escalation.
2. Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Presentation (314.00, F90.0): Ongoing cognitive symptoms, managed with Concerta.
3. Postconcussional Syndrome (310.2, F07.81): Persistent cognitive symptoms following multiple concussions, currently stable.
4. Adjustment Disorder with Mixed Anxiety and Depressed Mood (309.28, F43.23): Considered in the context of ongoing psychosocial stressors and mood symptoms.

Lucas is a motivated and engaged patient with a complex psychiatric and neurological history. He is currently stable on his medication regimen but has experienced increased fatigue, abnormal appetite, and weight gain since increasing fluoxetine to 40 mg daily. Cognitive symptoms remain stable, and there is no evidence of acute mood destabilization or neurological decline. He is motivated to reduce valproic acid due to cognitive side effects and lack of efficacy for headaches. He is actively engaged in occupational therapy and personal training sessions tailored for individuals with brain injury, which have provided notable benefit to his mood and overall well-being. There are no current safety concerns.

After meeting with the patient, we discussed the following:

1. Continue current regimen of valproic acid (1000 mg daily, transitioning to 750 mg in capsule form and 250 mg in oral solution), nortriptyline 40 mg daily, candesartan 100 mg daily, pantoprazole, rosuvastatin, Concerta (methylphenidate), and fluoxetine 40 mg daily.
2. Initiate gradual taper of valproic acid using oral solution, reducing by 50 mg increments (1 ml) every 2-3 weeks, as tolerated. Lucas may proceed with the next reduction to 2 ml as planned, but is advised to pause further tapering during the upcoming court trial if he experiences increased mood instability or distress. Monitor for withdrawal symptoms, mood changes, or irritability during the taper.
3. Continue with current occupational therapy and cognitive assessments as previously arranged. Continue personal training sessions for brain injury rehabilitation.
4. Educate patient and family on potential withdrawal symptoms and the importance of monitoring for irritability or mood changes during valproic acid taper. Emphasize medication adherence, sleep hygiene, and regular follow-up.
5. Prescription for valproic acid oral solution to be sent to the designated pharmacy. Lucas to contact the pharmacist regarding gastrointestinal side effects potentially related to the liquid formulation.
6. Consider lemborexant (Dayvigo) for sleep disturbances if hypnotic therapy is required, as an alternative to lorazepam to avoid dependence.
7. Arrange follow-up as needed based on symptom progression and patient communication. Lucas and his wife are aware to contact the care team if concerns arise during the taper.

I will continue to monitor Lucas’s progress closely and adjust the treatment plan as needed. Please do not hesitate to contact me if you have any further questions or concerns.

Priya Patel, MD
Psychiatry
Regional Medical Center