Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concern related to tardive dyskinesia (TD), such as involuntary movements of the face, tongue, limbs, or trunk.
History of Present Illness:
Onset and duration of involuntary movements.
Description of the movements (location, frequency, severity).
Impact of TD on daily activities and quality of life.
Medications currently used (focusing on dopamine antagonists) and history of past use.
Prior attempts to manage TD (medication adjustments, other interventions).
Past Medical History:
Underlying medical conditions that may be associated with TD (e.g., schizophrenia, bipolar disorder).
History of exposure to dopamine antagonists (duration, dosage).
Other relevant medical history (e.g., head trauma, stroke).
Medications:
List of current medications, including dosages, and specifically note any dopamine antagonists.
Social History:
Substance use (alcohol, illicit drugs) – can worsen TD.
Family History:
Family history of movement disorders or mental health conditions.
Physical Exam:
General examination (assess for overall health and signs of medication side effects).
Neurological examination:
Evaluate for involuntary movements (location, type, severity).
Assess for other neurological signs suggestive of underlying conditions.
Assessment:
Confirmation of TD diagnosis based on clinical presentation and history of dopamine antagonist exposure.
Severity of TD (mild, moderate, severe) based on the impact on daily activities.
Possible triggers or worsening factors for TD (specific medications, stress, underlying medical conditions).
Plan:
Treatment:
Discuss options for managing TD, considering:
Reducing or discontinuing dopamine antagonist medications if possible.
Switching to alternative medications with lower risk of TD.
Adding medications specifically for TD (e.g., amantadine, tetrabenazine) – use with caution and consider potential side effects.
Non-pharmacological interventions (e.g., physical therapy, occupational therapy) to improve function and manage symptoms.
Patient Education: Educate the patient about TD, treatment options, and potential side effects. Discuss the importance of medication adherence and follow-up care.
Follow-up:
Schedule follow-up appointments to monitor response to treatment, adjust medications as needed, and assess for potential complications.
Consider referral to a movement disorders specialist for complex cases.
Additional Notes:
Document any additional relevant information not covered above (e.g., discussion of the risks and benefits of continued dopamine antagonist use, considerations for underlying mental health conditions).
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. It is important to follow established guidelines for the diagnosis, treatment, and management of tardive dyskinesia