Problem: The patient reports being diagnosed with schizoaffective disorder, bipolar type. Her current medications are Depakote® 500 mg BID and risperidone 3 mg BID.
You notice that the patient is not making eye contact and does not appear to be blinking. Her effect is flat. She reports she stopped taking the risperidone because she wasn't feeling like herself. She reports feeling lethargic, "moving in slow motion," slurring her speech, weakness, and some tremors.
Currently, she reports feeling sad, anxious, and worried about how her medications are making her feel. She denies any suicidal ideation. She also denies any hallucinations. She states she is having difficulty sleeping at night because she is restless. She thinks this is making her mood and anxiety worse the next day. She is also feeling tired because she isn't sleeping well. She reports getting about 4 hours of sleep a night, but she wants to go to sleep.
What would be your assessment and plan for this patient based on the information provided? Include ICD-10 codes and what diagnostic criteria the patient meets for your diagnosis. Need Assignment Help?