Petunia Park Focused SOAP Note template

Petunia Park Focused SOAP Note template – Assessing, Diagnosing, and Treating Adults with Mood Disorders

Subjective

CC (chief complaint): “I have a history of taking medications and then stopping them. I do not think I need them. I feel like the medication squashes who I am.”

HPI: Petunia Park, 28, is a Caucasian bipolar disorder medication follow-up patient. Sleep deprivation led to her being caught outside inadequately dressed and disoriented three months ago, which got her hospitalized. Her pharmaceutical nonadherence is due to the belief that they “squash her creativity.” She experiences weekly bouts of depression that leave her exhausted, unmotivated, unable to get out of bed, overeating, and losing her creativity and self-esteem. This frequently occurs after one week of “high, high, high” mood, rushed speech, rushing thoughts, and impulsivity. When she has “lots of energy to do many things,” she sleeps 2-3 hours per night and feels rested (American Psychiatric Association, 2022). She obsesses about writing her autobiography, drawing, and producing music, believing she is talented enough to become renowned. Hypersexual, she seeks new partners due to increased libido. She denies suicidal/homicidal ideation but cites a 2017 overdose suicide attempt. She denies any manic or hypomanic episodes in the past three months while using lurasidone but says it made her feel different (Boland et al., 2022).

Substance Current Use

  • Nicotine: 1 pp. Not interested in quitting
  • Alcohol: None since age 19, when she realized it worsened her symptoms
  • Illicit drugs: Denies current use; tried cannabis once but became paranoid; denies any other lifetime use

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Past Psychiatric History

  • Bipolar I disorder with prior episodes of mania and psychosis, diagnosed in late adolescence.
  • Generalized anxiety disorder
  • ADHD
  • Multiple prior hospitalizations for mania with psychosis and one for suicidal gesture (overdose) in 2017
  • No history of suicide attempts or self-injurious behavior outside of overdose
  • No history of substance use treatment
  • Petunia Park Focused SOAP Note template

Family Psychiatric History

 

  • Mother with bipolar I disorder
  • Father with substance use disorder, currently incarcerated
  • Brother with likely schizophrenia but undiagnosed

Medical History

  • Hypothyroidism
  • Polycystic ovary syndrome

Current Medications

  • Levothyroxine 100mcg PO daily
  • Oral contraceptive pill (OCP)
  • Lurasidone 40mg PO BID (recently self-discontinued)

Allergies: NKDA

Reproductive Hx:

  • LMP last month
  • Sexually active with inconsistent condom use
  • Denies current STI symptoms or history of STIs
  • No history of pregnancy or abortion

ROS:

GENERAL: No weight loss, fever, chills, weakness or fatigue. Appetite increased with depression and decreased with mania.

HEENT: Denies visual changes, hearing loss, rhinorrhea, and sore throat.

SKIN: No rash or pruritis.

CARDIOVASCULAR: No chest pain, palpitations or edema.

RESPIRATORY: Denies cough, dyspnea, wheezing.

GASTROINTESTINAL: No nausea, vomiting, diarrhea, constipation, abdominal pain. Appetite increases significantly during depressive episodes, leading to weight gain.

GENITOURINARY: Denies dysuria, hematuria, and discharge. Reports increased libido during manic episodes leading to risky sexual encounters.

NEUROLOGICAL: No syncope, seizures, or focal neurological deficits. Denies current AH/VH. Prior episodes of grandiose auditory hallucinations when manic and sleep deprived, telling her she is “great and wonderfully talented.”

MUSCULOSKELETAL: Denies arthralgias, myalgias, joint swelling.

HEMATOLOGIC: Denies anemia, easy bruising, and bleeding. Has no known history of clotting disorders.

LYMPHATICS: No adenopathy.

ENDOCRINOLOGIC: Reports 5-10lb weight gain when depressed. Denies polyuria, polydipsia, and heat/cold intolerance.

Objective

VS: Sitting BP 138/88  | Pulse 90 | Temp 98.2 °F (36.8 °C) | Resp 18 | Wt. 160 lbs | BMI 27.1 | SpO2 100% RA

Labs: CBC, CMP WNL; TSH 6.3 mIU/L (H); Urine hCG negative; Urine drug screen negative

Physical Exam

  • General: Well-developed, well-nourished female dressed appropriately with good hygiene. No acute distress.
  • HEENT: Normocephalic/atraumatic, EOMI, PERRLA, notable mydriasis. Moist mucous membranes. No pharyngeal erythema or tonsillar exudates.
  • Neck: No JVD, lymphadenopathy, or thyromegaly.
  • Cardiovascular: Tachycardic rate, regular rhythm, no murmurs/rubs/gallops. Pulmonary: CTAB. No accessory muscle use.
  • Abdomen: Normoactive BS, soft, nontender, nondistended. No palpable hepatosplenomegaly.
  • GU: Deferred. Rectal: Deferred. MSK: No clubbing, cyanosis, or edema. Full ROM. 5/5 strength in upper and lower extremities.
  • Neuro: AOx3, no asterixis. Gait with a standard base.

Mental Status Examination

28-year-old cooperative, eye-contact-making woman. She is friendly and willing to talk about her art. Frequently gesticulating increases psychomotor activity. Speech is rushed but clear. Fluent, medium loudness, and prosody. The mood is “pretty good, a lot better than last week.” Bright, expansive affect, but impatient when probed about family history. The mental process is straight and goal-oriented with some circumstantiality. No conceptual drift or vague linkages. Grandiose fantasies about creative ability and renown. Denies auditory or visual hallucinations but says they can occur when manic and sleepless—denial of paranoia. Refuses suicide or homicidal thoughts; one low-lethality attempt with no present plan. Knowledge, attention, and abstraction-based cognition are intact. However, the severity of the condition and the need for treatment seem unclear. Hypersexuality lowered impulse control (Boland et al., 2022).

Differential diagnoses

  • Bipolar I disorder, severe manic episode with psychotic characteristics.
  • Substance/medication-induced bipolar and related disorder, with onset during withdrawal
  • Bipolar II disorder
  • Cyclothymic disorder
  • Borderline personality disorder

Bipolar I disorder fits the patient’s symptoms. She has alternating manic and depressed episodes lasting about a week. Her severe manic symptoms include decreased sleep, goal-directed activity, pressurized speech, idea flight, distractibility, grandiose delusions, and psychosis (American Psychiatric Association, 2022). These crises severely impair social and occupational performance. Manic episodes exclude bipolar II and cyclothymia, which constitute hypomania rather than mania (Yatham et al., 2018). Borderline personality disorder can cause emotional lability, impulsivity, and unstable relationships, but its symptoms are episodic and psychotic (Boland et al., 2022). Despite her negative urine drug test, quick lurasidone termination could cause withdrawal mania. Before lurasidone, she had many manic episodes, supporting the diagnosis of bipolar I disorder (American Psychiatric Association, 2022). Petunia Park Focused SOAP Note template

Reflections

This patient shows how difficult bipolar I disorder management is, especially for a patient with poor insight. Her hypersexuality and impulsivity put her in danger of unexpected pregnancy and STIs. Therefore, she needs safe sex practices and dependable contraception. Harmonizing her autonomy with the need to protect herself and others is ethical. If her manic symptoms develop, she may need involuntary hospitalization for stabilization (Goodwin et al., 2016). With consent, her family and support system could share collateral information and encourage drug adherence. Her brother’s untreated symptoms are likewise troubling and need evaluation.

Sociocultural, her creative endeavors define her; therefore, it is important to validate them while informing her about untreated mania. Exploring her medication attitudes and resolving adherence hurdles such as cognitive dulling anxiety may avoid relapses (Geddes & Miklowitz, 2013). Her mother’s bipolar condition may offer psychoeducation and therapy models. Avoiding medical depression requires monitoring and treating her hypothyroidism.

Case Formulation and Treatment Plan

Bipolar I condition causes manic and depressed episodes with remission. However, this patient cycles faster and has more mood episodes (Boland et al., 2022). Her late adolescent onset is usual, and her family history of bipolar disorder and other psychiatric diseases suggests hereditary loading. She may be grandiose when manic, but her creativity gives her purpose and self-esteem. Though she may have been euthymic on lurasidone before, its abrupt cessation certainly caused her manic episode.

Stabilizing mood and preventing relapse are treatment goals. Lithium is the first-line treatment for bipolar I illness and reduces suicidal behavior (Yatham et al., 2018). Given her impulsivity and questionable adherence, a long-acting injectable (LAI) antipsychotic may be better for quick stabilization. Risperidone LAI prevents manic relapse and maintains therapeutic levels even if she misses an injection (Fountoulakis et al., 2016). Start with 25mg IM q2 weeks and titrate as needed. Monthly doses of aripiprazole monohydrate are another option. If LAI monotherapy fails, lithium may be added (Goodwin et al., 2016).

When euthymic, psychotherapy is needed. Cognitive-behavioral and interpersonal therapy can challenge medication misperceptions, increase coping skills, regulate sleep/activity, and strengthen therapeutic alliances (Geddes & Miklowitz, 2013). If her support system participates, family-focused therapy may lower relapse risk. Psychoeducation on bipolar disease can help patients understand their illness, recognize relapse signs, and create a crisis plan. To track symptoms and overcome adherence hurdles, frequent follow-up is necessary.

Optimizing her thyroid function is medically necessary to prevent depression. If these drugs are started, lithium and valproate levels must be checked (Yatham et al., 2018). Given her sexual behaviors, mood stabilizer teratogenicity education and dependable contraception are essential. STI screening and safer sex counseling should be routine. Finally, fostering healthy habits like exercise, stress management, and drug abstinence can boost resilience and wellness. Evidence-based medication plus a thorough psychosocial approach may improve symptoms and functioning. Bipolar I disorder is chronic and recurring. Therefore, constant care and vigilance are necessary to preserve stability and quality of life.

References

American Psychiatric Association. (2022). Bipolar and related disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787.x03_Bipolar_and_Related_Disorders

Boland, R. Verdiun, M. L. & Ruiz, P. (2022). Kaplan & Sadock’s synopsis of psychiatry (12th ed.). Wolters Kluwer.

Fountoulakis, K. N., Yatham, L., Grunze, H., Vieta, E., Young, A., Blier, P., Moeller, H. J., & Kasper, S. (2016). The International College of Neuro-Psychopharmacology (CINP) treatment guidelines for bipolar disorder in adults (CINP-BD-2017), part 2: Review, grading of the evidence, and a precise algorithm. International Journal of Neuropsychopharmacology, 20(2), 121-179. https://doi.org/10.1093/ijnp/pyw100 Petunia Park Focused SOAP Note template

Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. The Lancet, 381(9878), 1672-1682. https://doi.org/10.1016/s0140-6736(13)60857-0

Goodwin, G. M., Haddad, P. M., Ferrier, I. N., Aronson, J. K., Barnes, T. R. H., Cipriani, A., Coghill, D. R., Fazel, S., Geddes, J. R., Grunze, H., Holmes, E. A., Howes, O., Hudson, S., Hunt, N., Jones, I., Macmillan, I. C., McAllister-Williams, H., Miklowitz, D. M., Morriss, R., Munafò, M., … Young, A. H. (2016). Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 30(6), 495–553. https://doi.org/10.1177/0269881116636545

Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O’Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., McIntyre, R. S., … Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97–170. https://doi.org/10.1111/bdi.12609