Patient: Ashwini Srinivasamohan (35F) | DOB: 08/27/1990
Visit Date: March 5, 2026
Reviewer: Psychiatric MD Collaborator
Review Date: March 19, 2026
Collaborating Provider: Stacy Pascarella, APRN
The clinical decision-making demonstrates comprehensive medication management, appropriate risk mitigation, and strong patient-centered care. The current course is reasonable and approvable with specific recommendations to optimize outcomes.
| Diagnosis | Code | Status | Recommendation |
|---|---|---|---|
| Bipolar II Disorder, Current Episode Depressed, Moderate | F31.32 | ✅ Appropriate | Maintain; mood stability confirmed; no hypomanic symptoms |
| ADHD, Unspecified Type | F90.9 | ✅ Appropriate | Maintain; partial response; formulation change indicated |
| Generalized Anxiety Disorder | F41.1 | ✅ Appropriate | GAD-7 score of 11 supports moderate anxiety |
| Alcohol Dependence, In Remission | F10.21 | ✅ Appropriate | Naltrexone-supported; 2 drinking episodes since last visit |
| Binge Eating Disorder, Unspecified | F50.819 | ⚠️ Consider formal assessment | PHQ-9 Item 5 score 3; consider BES (Binge Eating Scale) |
| Drug-Induced Subacute Dyskinesia | G24.01 | ✅ Appropriate | Geodon-induced; AIMS score 7 (minimal); stable |
| Additional consideration: Nightmare Disorder (F51.5) — persistent despite prazosin; warrants separate specification and targeted intervention. | |||
| Medication | Dose | Assessment | Recommendation |
|---|---|---|---|
| Venlafaxine XR | 187.5mg daily | Reasonable with caution | SNRI in bipolar disorder requires mood stabilizer coverage. Monitor for mood elevation. |
| Lamotrigine | 100mg daily | ⚠️ Subtherapeutic | Target 200mg for acute bipolar depression. Consider titration to 150-200mg. |
| Adderall IR → XR | 30mg daily | Appropriate | IR with afternoon crash indicates inadequate duration. XR conversion approved. |
| Naltrexone | 50mg daily | Appropriate | Effective for alcohol craving; continue with mandatory LFT monitoring. |
| Prazosin | 2mg nightly | ⚠️ Questionable efficacy | Nightmares persist; consider discontinuation trial or dose optimization. |
| Doxepin | 10mg nightly | Appropriate | Low-dose TCA for sleep maintenance; minimal anticholinergic effects. |
| Gabapentin | 300mg PRN | Appropriate | Anxiolytic use; monitor for tolerance and misuse potential. |
| Propranolol | 20mg BID PRN | Appropriate | Performance/situational anxiety; monitor for hypotension. |
Rationale: Current 100mg is subtherapeutic for acute bipolar depression. Evidence supports 200mg as target dose.
Action: Titration schedule: 100mg × 2 weeks → 150mg × 2 weeks → 200mg maintenance. Monitor for rash.
Rationale: Afternoon crash on IR indicates inadequate duration. XR provides smoother coverage.
Action: Convert Adderall IR 30mg to XR 30mg morning. Monitor for sleep disruption.
Rationale: Nightmares persist despite 2mg nightly. Uncertain benefit after adequate trial.
Action: Consider 4-week discontinuation trial with nightmare diary. Evaluate for PTSD features if nightmares persist off medication.
| Risk Domain | Level | Mitigation Strategy |
|---|---|---|
| Antidepressant-induced mania (venlafaxine) | Moderate | Lamotrigine coverage; close mood monitoring |
| Liver toxicity (naltrexone) | Moderate | Scheduled LFT monitoring; patient education |
| Tardive dyskinesia progression | Low | Quarterly AIMS; stable current score |
| Stimulant misuse/diversion | Low | XR formulation reduces abuse potential |
| Alcohol relapse | Moderate | Naltrexone adherence; counseling support |