Bipolar Disorder SOAP Note
Subjective:
Chief complaint (in patient’s own words): “I’ve been feeling really up and down lately. One minute I’m on top of the world and can’t stop moving and talking, and the next I’m crashing hard and just want to stay in bed all day.”
History of present illness: The patient is a 28-year-old female who presents with worsening symptoms of bipolar disorder over the past 2-3 weeks. She reports experiencing periods of elevated mood, increased energy, racing thoughts, pressured speech, and a decreased need for sleep alternating with periods of depressed mood, fatigue, lack of motivation, and social withdrawal. During the manic phases, she describes feeling “like I’m on fire and can conquer the world.” She has exhibited impulsive behaviors such as excessive spending and hyper-sexuality. She states, “I went on a huge shopping spree and maxed out three credit cards buying unnecessary things.” She has also experienced periods of irritability and has had conflicts with family members during these episodes. The depressive episodes are characterized by persistent low mood, anhedonia, poor concentration, feelings of worthlessness, and thoughts of “not wanting to go on.” She reports difficulties getting out of bed and a lack of self-care during these times
Bipolar Disorder SOAP Note
Current Medications: Lithium 600 mg daily, Aripiprazole 10 mg daily
Allergies: No known drug allergies
Past Medical History: Unremarkable
Past Psychiatric History: Diagnosed with Bipolar I Disorder at age 22 after first manic episode with psychotic features requiring hospitalization. Multiple subsequent episodes over the years.
Family History: Mother has a history of major depressive disorder.
Relevant personal and social history: The patient is currently unmarried and lives alone in an apartment. She has a close relationship with her parents, who provide support, but strained relationships with some other family members due to the erratic nature of her illness. She works part-time as a graphic designer but has struggled to maintain consistent employment during acute episodes. She denies any history of substance abuse or legal issues. No recent significant psychosocial stressors were identified.
Objective:
Vitals: BP 132/88, HR 98, RR 16, Temp 98.6°F
ROS: Positive for sleep disturbance, poor concentration, pressured speech as described above. Otherwise negative.
Bipolar Disorder SOAP Note
Mental Status Exam:
- Appearance – Disheveled, overly groomed with excessive makeup
- Behavior – Hyperactive, fidgety, easily distracted
- Speech – Loud, pressured, rapid rate
- Mood – Euphoric
- Affect – Mood-congruent, labile, broad range
- Thought Process – Flight of ideas, tangential Thought Content – No overt delusions or paranoia
- Perceptions – Denies hallucinations
- Cognition – Intact attention and concentration, recent/remote memory intact
- Insight – Fair, minimizes symptoms at times
- Judgment – Fair Other – Psychomotor agitation
Psychiatric Screening Measures: PHQ-9 – 6 (Minimal depression)
MDQ – Positive screen for bipolar disorder
Psychiatric Screening Measures:
PHQ-9 – 6 (Minimal depression) MDQ – Positive screen for bipolar disorder (Roberts, L. W. (Ed.). (2019).
Assessment:
Diagnosis: Bipolar I Disorder, Current Episode Manic, Severe (F31.2)
DSM-5 Criteria Met:
- Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy
- Mood disturbance sufficient to cause marked impairment in social/occupational functioning
- At least 3 of the following (4 if mood is only irritable): grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, excessive involvement in pleasurable activities with potential for painful consequences
- Not attributable to physiological effects of a substance or other medical condition (American Psychiatric Association. (2013).
Potential Obstacles to Treatment:
- Medication non-adherence
- Lack of consistent social support system
- Vocational and financial instability
- Potential for insight to worsen during acute manic episodes
- Stigma associated with mental illness
Bipolar Disorder SOAP Note
Plan:
- Adjust medication regimen:
- Increase lithium dose to 900 mg daily (obtain lithium level after 5 days)
- Increase aripiprazole to 20 mg daily
- Add lorazepam 1-2 mg every 6 hours as needed for agitation/insomnia (Roberts, L. W. (Ed.). (2019).
- Refer to partial hospitalization program for intensive therapy, psychoeducation on bipolar disorder, and medication management. Coordinate family involvement.
- Psychotherapy:
- Individual therapy focused on cognitive behavioral strategies, coping skills, trigger identification
- Family therapy to increase support system’s understanding of the illness
- Encourage maintaining regular sleep/wake cycle, limiting potential triggers (caffeine, stress), and engaging in relaxation techniques like mindfulness.
- Consider involvement of case manager or community resources to assist with adherence and functional support during acute episodes. (McIntyre et al., 2020)
- Follow up appointment in 2 weeks:
- Assess response to medication changes and need for further adjustments
- Evaluate for presence of depressive or psychotic symptoms
- Review any labs (lithium level, metabolic monitoring)
- Coordinate step-down level of care if stabilized (Roberts, L. W. (Ed.). (2019).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., … & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841-1856. https://doi.org/10.1016/S0140-6736(20)31544-0
Roberts, L. W. (Ed.). (2019). The American Psychiatric Association publishing textbook of psychiatry. American Psychiatric Pub. APA.