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Improving Outcomes in TD

CE / CME

Case Challenge: Irregular, Uncontrolled Movements Impairing Social Life

Physician Assistants/Physician Associates: 0.75 AAPA Category 1 CME credit

Social Workers: 0.75 ASWB ACE CE Credit

Pharmacists: 0.75 contact hour (0.075 CEUs)

Psychologists: 0.75 APA CE Credit

Nurses: 0.75 Nursing contact hour, including 0.75 hour of pharmacotherapy credit 

Physicians: Maximum of 0.75 AMA PRA Category 1 Credit™

Released: December 08, 2022

Expiration: December 07, 2023

Jeremy A. Schreiber
Jeremy A. Schreiber, MSN, APRN, PMHNP-BC
CME/CE Information

Activity

Progress
1
Course Completed

Case Introduction

Trevor, a 56-year-old man, presents to your outpatient psychiatric office for an evaluation after being discharged from the hospital 2 days ago. After presenting to the emergency department in a manic state (his first), he was on the inpatient psychiatric unit for 5 days, during which time he was diagnosed with bipolar disorder. While inpatient, he was started on quetiapine and titrated to 400 mg, which alleviated his symptoms. The bipolar disorder is under good control, and Trevor reports tolerating medication without adverse events. 

Trevor’s psychiatric history is otherwise unremarkable: no previous psychiatric hospitalizations; no episodes of depression, mania, psychosis, or anxiety; no treatment by psychiatric providers; and no psychiatric treatment from his family physician. He is partially deaf in his right ear and his wife accompanies him to assist with communication, and she corroborates his psychiatric history. 

The hospital records reveal that Trevor has a history of hypertension and hyperlipidemia, although he is not receiving any medication for hypertension at this time. When he found out he had hyperlipidemia, his wife encouraged him to take medication to reduce his chance of having a heart attack. He is adherent to the atorvastatin that he started approximately 2 years ago. He reports during the past 20 months, he has been watching his diet, exercising 3 times per week, and has lost approximately 45 lbs.

During today’s visit, it is noted that Trevor has repetitive involuntary hyperkinetic movements of his jaw, tongue, and fingers. He reports that these movements do not bother him, despite the tongue movements episodically interfering with his speech. 

Appearance: well groomed
Musculoskeletal: normal gait and station; hyperkinetic movements of jaw, tongue, and fingers
Behavior/attitude: pleasant, cooperative
Speech/language: normal rate and rhythm with occasional pronunciation problems
Thought content: no obsessions, preoccupations, or phobias noted; no suicidal or homicidal ideation; no delusions or ideas of reference
Thought process: logical, coherent, and goal directed
Associations: intact
Mood: “good”
Abstraction: intact and able to relay the meaning of “birds of a feather flock together”
Insight: fair

Laboratory findings: Comprehensive metabolic panel, complete blood count, lipid panel, and fasting blood glucose are all grossly unremarkable.

Family history is unremarkable for psychiatric disorders and otherwise noncontributory.

Current medications: quetiapine 400 mg PO once daily, atorvastatin 40 mg PO once daily

What is the appropriate next step for Trevor?