A case study of Bipolar Disorder

Psychiatric SOAP Note

Bipolar Disorder

CriteriaClinical Notes
SubjectiveThe patient is an 84-year-old woman. The patient has a full-time caregiver and is a member of a group therapy program. The patient was brought in by the caregiver, who reports a change of behavior and agitation. The patient has a history of Bipolar disorder and moderate dementia.  . The patient is paranoid, has trouble sleeping, and has shown aggressive behavior. The patient is currently on Depakote 1500 mg daily to treat the mania and quetiapine 100 mg for the depressive episodes as well as psychosis. The patient is also taking bupropion 75 mg QD. For the depression.  
Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.  
Objective     The patient seems restless.The patient had notable trouble in speech; he drifts from conversation easily, showing a lack of concentration. The patient looked tired and agitated. His skin is dry, and he looks unkempt, a sign that he is not taking good care of himself.  The patient shows signs of paranoia; he does not trust the hospital staff and wants to leave. The preliminary diagnosis for bipolar disorder includes a physical examination of the patient and lab tests to determine the cause of the symptoms. A psychiatric assessment is also carried out by a psychiatrist who will discuss the patient’s feelings, thoughts, and behavioral patterns. Family and friends may also be interviewed during the assessment. The doctor may ask for a mood chart where the patient records their daily moods and sleep patterns as well as other issues they may experience (Marangoni, De Chiara &Faedda, 2015). The doctor uses this information to compare the patient’s symptoms with the criteria provided for diagnosing bipolar disorder  
This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…” Include MSE, risk assessment here, and psychiatric screening measure results.
AssessmentSymptoms of bipolar disorder The patient suffers from bipolar I disorder. In Bipolar I disorder, the patients may experience one major manic episode that is often followed or preceded by major depressive episodes. In extreme cases, the manic episode may lead to psychosis. In bipolar II disorder, the patients may experience a significant depressive or hypomanic episode without ever having a manic episode (Vieta et al., 2018).  Other common symptoms of bipolar disorder include increased agitation or activity, racing thoughts, talkativeness, lack of sleep, jumpiness, euphoria, impulsiveness. If the patient is going through a major depressive episode, the symptoms may be severe enough to interfere with the patient’s daily activities such as relationships, work, and school activities as in the case of EL Some of the symptoms of a major depressive episode include feelings of sadness and hopelessness. In this case, the patient may feel empty and maybe tearful (Vieta et al., 2018). The patient also loses interest in activities that they previously found exciting and may not get pleasure from normal activities and hobbies. The patient may lose weight due to a lack of appetite due to depression. The patient will show signs of fatigue due to sleeplessness and may become restless or show slowed behavior. Excessive guilt and feelings of worthlessness affect bipolar patients since they feel like they are a burden to family and friends (Marangoni, De Chiara & Faedda, 2015). Patients also find it challenging to make decisions and concentrate, and in some cases, the patient may be planning or considering suicide.  
Include your findings, diagnosis, and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.
PlanThe patient is already under medication using Depakote 1500 mg daily to treat the mania and quetiapine 100 mg for the depressive episodes as well as psychosis. The patient is also taking bupropion 75 mg QD. For the depression. Treatment for psychosis involves managing the symptoms depending on the patient’s state of health. Medications such as mood stabilizers are used on patients with bipolar disorder to help with the mood swings and emotional distress caused by the disease. These medications help to suppress the chemicals that cause mood swings. Examples of medicines used to treat and manage bipolar disorder symptoms include mood stabilizers to control the manic and hypomanic episodes. Antidepressants are administered to the patient to manage the depression and antipsychotic drugs to help with help control the mania (Cipriani& Holmes, 2016).Anti-anxiety medication is also used to reduce anxiety attacks and to improve sleep. I would then recommend that the patient starts weekly therapy sessions with a psychiatrist until he is stable. Bipolar disorder is a lifelong condition that requires continued treatment even when the patient shows no symptoms. The continual treatment is meant to prevent the patient from relapsing by suppressing the symptoms. Doctors may recommend daily treatment programs such as support groups and counseling to help patients to deal with the symptoms and the stigma associated with mental health ( Cipriani& Holmes, 2016).  In extreme cases, Bipolar disorder patients may require hospitalization. Hospitalization is recommended for patients with suicidal thoughts and tendencies. I will, therefore, recommend that the caregiver pays extra attention to the patient’s behaviors in case of suicidal tendencies. The patient should report back for evaluation after a month.  
Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options, and complementary therapies, and rationale for your decisions. Include when you want to see the patient next. This comprehensive plan should relate directly to your assessment.

References

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Goodwin, G. M., Haddad, P. M., Ferrier, I. N., Aronson, J. K., Barnes, T. R. H., Cipriani, A., …& Holmes, E. A. (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.

Marangoni, C., De Chiara, L., & Faedda, G. L. (2015). Bipolar disorder and ADHD: comorbidity and diagnostic distinctions. Current psychiatry reports, 17(8), 67.

Vieta, E., Salagre, E., Grande, I., Carvalho, A. F., Fernandes, B. S., Berk, M., …& Suppes, T. (2018). Early intervention in bipolar disorder. American Journal of Psychiatry, 175(5), 411-426.

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