SOAP NOTE 2
Week 12 soap note.
Patient Information: S.O, 25-year-old, Caucasian female
CC: “I keep crying at work and my boss asked that I see my doctor or he will let me go”.
S.O is a 25-year-old Caucasian female presenting to the clinic after a referral from her primary care physician. She was recently evaluated for mood and functional changes at work. She reports feeling down for the past month with some better days but has been feeling sad daily for the past two weeks. She states that she has felt like giving up and has had intermittent suicidal thoughts, such as almost cutting herself with a razor while taking a shower. She reports that worst she has ever done was cut her arms a few times in high school. She reports a similar episode in college. Her symptoms then improved after a few months both times. She states that she would not end her life because of her family and its against her religion. Associated symptoms include; difficulty concentrating, hypersomnia, crying episodes, feelings of guilt and self, and eating all the time with a weight gain of 10 pounds in the past month. She also reports that about six weeks prior she felt creative during her writing class and ended up staying up all night to finish her writing. She reports not feeling tired the next day. Besides, she also went out to a bar by herself and met a man after been up and not sleeping for a few days. She had extra drinks and almost went to the man’s house. S.O reports that her she fears losing her work and cannot stop thinking about all the mistakes she has made at work.
Daily multivitamin one daily by mouth.
Birth control Ortho tri-cyclen one tab daily by mouth
Past Psychiatric and Medical History: healthy except for increased weight.
Past Hospitalization: one hospitalization when she had an appendectomy at the age of 13.
Mother committed suicide, had schizophrenia.
Father was an alcoholic.
Sister has depression and on Fluoxetine.
Married to her high school sweetheart for about one year and a half. Husband supportive. No children. Has a fulltime job where she reports making constant errors. Reports drinking two glasses of wine during the weekends. History of binge drinking with black out episodes years ago. Reports drinking a lot six weeks ago when she met a guy at the bar. Smokes weed once a month. Last time she smoked weed was two years ago. Denies use of any other substances or IV drug use.
Mental Status Exam (MSE)
General Appearance and behavior: Caucasian female overweight in appearance. She is dressed in shorts and a sleeveless top appropriate for the weather. Appears slightly older than her stated age. She reports age 23 while records indicate she is 25. Her skin is clear with no signs of bruising, tattoos, lesions, rashes, cuts, or use of intravenous drug use. She is well groomed, with no noted odors, and her hair is healthy appearing and tied in a pony tail. No odor noted. She maintains eye contact and is cooperative throughout the interview. Her energy level during the interaction appears low and has a sad expression on her face.
Motor Activity: Motor activity is slowed with a slumped over posture. Her gait is also slowed with no apparent pacing, restlessness, or any other unusual movements.
Speech: The rate and speed of speech is reduced with normal volume. It is easy to follow and understand her. No stuttering or word finding difficulties. Tone of speech is normal and quiet. Articulation is clear and spontaneous.
Mood: She describes her current mood as sad, feeling tired, wanting to sleep all day, and has felt like giving up. She notes that six weeks prior her mood was more elevated with moments of staying up at night a few nights without need to sleep and also going out on her own to a bar.
Affect: Her affect is congruent with her described mood and content of speech. She appears sad, tearful, and appears worried. has a worried appearing affect.
Thought Content: Her thought content is spontaneous and responds to questions appropriately. No perseveration or rumination on certain content or thoughts noted. No noted compulsions noted. Denies delusions. No noted ideas of reference, magical ideation or elusions. Reports depressive thoughts including feelings of guilt, hopeless, and anhedonia. She reports suicidal thoughts. Denies suicidal intent, plan, or preparation. Reports intermittent thoughts of cutting herself with a razor but reports that she would not do it because of her family and her beliefs. Denies homicidal ideation. Denies phobias. She reports being paranoid that her work mates are trying to her get her lose her job.
Thought Process: Her thought process is well associated, coherent, logical, linear, and goal-directed. She stays on topic and does not include non-relevant information. No preservation of a certain topic and no thought blocking noted. Stays on topic and it us easy to follow her thoughts.
Perceptual Disturbances. She denies auditory, visual, tactile, olfactory, gustatory hallucinations. No illusions, depersonalization, or derealization noted or reported.
Cognition: Alert and oriented x4. She maintains concentration and responds to questions appropriately.
Insight: Her insight on her condition is poor. She reports that she saw her doctor because her supervisor told her she had to see a doctor and get assessed or otherwise she would lose her job. She did not recognize herself that her symptoms might be related to a psychiatric condition. She agrees that her symptoms affect her overall functional status.
Judgment: Her judgement is poor. She reports that a few weeks ago she went out alone without her husband with some his male friends and went to a bar by herself where she met a strange man and binged on alcohol. She almost went to the strange man’s house after he invited her. She declined the offer and continued drinking and does not recall how she got home.
Attention/Concentration: Intact. Able to respond appropriately to all questions and stays on topic.
MMSE: able to repeat and perform all questions asked. Score 30/30.
Safety Risk: moderate.
Blood pressure: Sitting:110/76, Standing: 94/72
Pulse: 68 bpm, regular.
Respirations: 14 room air, regular.
Oxygen saturation: 97% on room air and at rest.
Weight: 175.0 lbs. Height 5.3. BMI 31.0
Skin, hair, nails: skin clear with no bruises, marks, or signs of IV drug use. No signs of hair loss. Nails clean, short, with normal capillary refill.
HEENT: normocephalic head with no lumps, lesions, tenderness, or trauma. Symmetric face, no drooping, no weakness, and no involuntary movements. Snellen chart 20/20 bilateral eyes. Intact extraocular movements. PEERLA. No unusual breath detected.
Neurological: Gait normal. No tremors noted. All reflexes, symmetrical deep tendon reflexes at 2+. Romberg negative.
Musculoskeletal: full range of motion with smooth movements. No tenderness or swelling noted.
Screenings & Diagnostics
· Human immunodeficiency virus (HIV), Western blot: Negative. To rule out HIV infection based on her presenting symptoms and recent change in behavior.
· Drug toxicology testing, blood: None detected. To rule out substance or medication induced bipolar disorder.
· HCG Urine: to rule out pregnancy before initiating any psychotropics.
· The Mood Disorder Questionnaire. Tool to assist in identifying bipolar symptoms.
Bipolar II Disorder, F31.81
Diagnosis criteria for bipolar 11 disorder per DSM-5 include having at least one episode of hypomania and major depression. There is should be no history of mania. Symptoms in either episode are as follows:
1. A discrete period of unusual and persistent increased, expansive, irritable mood with unusual increased energy level, lasting at least four consecutive days and occurs most of the day, almost daily.
2. Three or four when mood is only irritable of the following symptoms: increased self-esteem, reduced need for sleep, increased talking, flight of ideas, easily distracted, increased psychomotor agitation or goal directed actions, and risky behaviors.
3. The period is associated with significant change in normal functioning.
4. Disturbance is noticeable by others.
5. Episode is not severe enough to impair normal functioning.
6. The episode cannot be attributed to other causes such as drug use, medication, or other treatments.
Major Depressive Episode.
1. There are five or more of the following symptoms lasting for two weeks and represent a change from regular functioning: depressed throughout the day, increased lack of interest or pleasure in all, or almost all normal activities, weight loss or weight gain, insomnia or hypersomnia almost daily, psychomotor retardation or agitation, fatigue, feelings of guilt or worthlessness, decreased concentration or thinking, and recurrent death thoughts.
2. Symptoms cause significant clinical distress in social, work, and other areas.
3. Episode is not related to other physiological effects (American Psychiatric Association, 2013, p. 132-133).
S. O meets the criteria for bipolar 11 disorder because she has hypomanic and depressive symptoms. More importantly her symptoms do not qualify for a manic episode. Additionally, the mood episodes cannot be explained by other illnesses such as schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. Her symptoms are less severe than manic symptoms and does not require or lead to hospitalization. Besides, her symptoms have not lasted at least seven days and neither is her psychosocial functioning severely impaired, unlike in a manic episode (Suppes, 2019). Bipolar 1 disorder is therefore ruled out based on these findings making Bipolar 11 disorder the most likely diagnosis.
Persistent Depressive Disorder, F34.1
The DSM-5 criteria for persistent depressive disorder is as follows:
1. Depressed mood majority of the day, with more days than not.
2. Presence of two of the following symptoms: decreased or increased appetite, insomnia or hypersomnia, decreased energy, poor self-esteem, reduced concentration, and feelings of hopelessness.
3. The individual has not been without the symptoms in criteria 1 and 2 for more than two months at a time in two years.
4. Major depressive disorder criteria can be present for two years.
5. Absence of a manic episode or hypomanic episode.
6. The issue is not explained by other psychiatric conditions.
7. Symptoms are not related to physiological effects like use of medications or drugs.
8. There is significant impairment in social, occupational functioning (American Psychiatric Association, 2013, p. 168-169).
S.O does not meet the criteria for this diagnosis as she reported having recovered from previous depressive episodes (Simon, 2019). Furthermore, she has hypomanic symptoms making this an unlikely diagnosis.
Borderline Personality Disorder, F60.3
The fundamental characteristics of borderline personality disorder comprises unstable interpersonal relationships, self-image, affect, and noticeable impulsivity, that begins early in adulthood and is present in a variety of settings as demonstrated by five of the following:
· Desperate efforts to prevent real or imagined abandonment.
· A pattern of unstable and intense interpersonal relationships.
· Unstable self-image or disturbed self-image.
· Impulsive behavior.
· Repeated suicidal behavior.
· Unstable affective behavior marked by mood changes.
· Chronic feelings of emptiness.
· Inappropriate increased anger or difficulty managing anger.
· Paranoid ideation or serious dissociative symptoms that are transient (American Psychiatric Association, 2013, p. 663).
This diagnosis is probable based on the rapid changes in mood and impulsive behavior presented by S.O. This diagnosis is however unlikely because borderline personality disorder is not associated with energy and sleep disturbances as in the case of S.O (Skodol, 2019).
Substance/Medication-Induced Bipolar Disorder, F19.14
The DSM-5 diagnostic criteria include:
· A major disturbance in mood that persists and dominates with symptoms of elevated, irritable, expansive mood with or lacking depressed mood.
· History, physical examination, or laboratory values indicate either or both of the following: substance intoxication, exposure, or withdrawal of a medication and the medication of substance is capable of producing the in the first element.
· The disturbance cannot be explained by a disorder such as bipolar or other related disorder.
· The disturbance does not occur only during a delirium.
· There is significant clinical distress or impairment in daily functioning (American Psychiatric Association, 2013, p. 142).
It is important to screen patients presenting with mood symptoms for alcohol, prescription, and illegal drug use. This diagnosis because S.O reports use of alcohol and smoking weed. Mood symptoms can result from alcohol abuse (Weiner et al., 2018). Furthermore, her drug toxicology testing was negative making this diagnosis unlikely.
Treatment will be based on a thorough assessment of S. O while paying particular attention to her safety and those around her. It will be also important to consider possible comorbidities and a detailed history of the presenting symptoms. She will be assessed using the Mood Disorder Questionnaire to accurately screen for bipolar disorder symptoms (Suppess, 2019). She will be evaluated for suicide risk by asking about suicide ideation, and how prepared she is. Her spouse and any supportive family members will be included in the treatment as well in assessing for suicide risk. Assess of means and lethality of the means will be determined. S.O risk appears to be minimal. However, it will still be important to monitor and involve her support system in the monitoring for suicide risk.
S.O and her family will be educated on the diagnosis and treatment options. Printed teaching materials and reliable websites will be provided (American Psychiatric Association, 2002).
S.O will be involved in the treatment plan and in choosing medication. Side effects profile, her gender, age, the severity of her symptoms, past medical history, allergies, among other factors will be put into consideration while choosing the medication. To increase compliance, lithium will be initiated as monotherapy if S.O agrees. Factors like her general medical history of renal, thyroid, cardiac, and pregnancy will be considered before initiating lithium (American Psychiatric Association, 2002). S. O will be instructed on the benefits and side effects associated with lithium. Lithium is more widely studied and has been proven to more effective in reducing the risk of suicide in patients diagnosed with a mood disorder (Stovall, 2019). S.O is already on birth control which she will be counseled to maintain taking while on lithium-based on the fact the lithium has a small risk of Ebstein’s anomaly heart defect when taken during the first trimester (Stahl, 2017). She will be instructed about possible side effects including neurological effects such as tremors and cognitive effects, weight gain that might be related to lithium-induced hypothyroidism, renal effects such as polyuria, gastrointestinal effects, dermatological effects, cardiac effects, and lithium toxicity and overdose. She will be instructed to report signs of lithium toxicity which include neurological symptoms such as tremor, dysarthria, and ataxia; gastrointestinal symptoms; cardiovascular changes, and renal impairment (American Psychiatric Association, 2002). She will also be instructed on later lithium toxicity symptoms that may occur such as impaired consciousness, muscular fasciculations, seizures, myoclonus, and coma. Lithium toxicity is a medical emergency, with a potential cause of permanent neuronal damage and death. Lithium should be stopped and dehydration treated in case of lithium toxicity. Sodium polystyrene sulfate or Kayexalate or polyethylene glycol solution can be used to remove unabsorbed lithium from the gastrointestinal tract (Sadock et al., 2014). S. O will also be instructed on drug interactions of lithium with medications such as diuretics, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, and angiotensin-converting enzyme inhibitors (American Psychiatric Association, 2002). S.O will be instructed on the importance of staying hydrated and not to drink alcohol while taking lithium. Dehydration and consuming alcohol can increase the risk of lithium toxicity (Sadock et al., 2014).
Initial laboratory checks will include serum creatinine, electrolytes, thyroid function (TSH, T3, and T4), complete blood count, ECG, and a pregnancy test will be done before starting lithium. S. O will be started on a dose of 300 mg twice daily and then titrated up depending on lithium plasma levels which is should be between 0.8 and 1.2 mEq/L. Initial lithium levels will be checked after a steady state is reached usually after five days with emphasis to have the labs drawn twelve hours after the last dose. Regular serum lithium monitoring will then be obtained every two to six months with exception of lithium toxicity signs, if dosing is adjusted, or when there is suspicion that the patient is not adhering to treatment (Sadock et al., 2014).
Several psychotherapy interventions are efficacious when in used together with pharmacotherapy in the treatment of bipolar disorder. Cognitive-behavioral therapy (CBT), psychoeducation, family, and interpersonal therapies are among the best studied interventions (American Psychiatric Association, 2002). S.O will also be offered weekly sessions of CBT to assist in improving her symptoms and overall functioning. She will be taught to identify and modify negative harmful thoughts and actions through interventions such as exposure and stimulus management. Also, she will be instructed about her diagnosis as well as coping skills to manage her stressors. Several meta-analysis studies have revealed that CBT as an adjunct to pharmacological treatment can reduce bipolar mood episodes recurrence (Vieta & Colom, 2019).
S.O will be seen in a week. Her lithium serum levels in addition to other labs including creatinine, thyroid function will be checked. Response to medication and CBT including any side effects, reduction in symptoms, and adherence to medication will be assessed and changes made as needed.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing.
American Psychiatric Association (2002). Practice guideline for the treatment of patients with panic disorder Treatment of Patients with Bipolar Disorder, Second Edition. Retrieved from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf.
Suppes, T. (2019). Bipolar disorder in adults: Assessment and diagnosis. UptoDate. Retrieved July 23, 2020, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/bipolar-disorder-in-adults-assessment-and-diagnosis?search=bipolar%20ii%20disorder&topicRef=14642&source=see_link.
Sadock, B. J., Sadock, V. A. & Ruiz, P. (2014). Synopsis of psychiatry (11th ed.). Lippincott, Williams, & Wilkins.
Simon, G. (2019). Unipolar major depression in adults: Choosing initial treatment. UptoDate. Retrieved July 26, 2020, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/unipolar-major-depression-in-adults-choosing-initial-treatment?search=Persistent%20Depressive%20Disorder§ionRank=1&usage_type=default&anchor=H21696602&source=machineLearning&selectedTitle=2~150&display_rank=2#H21696602.
Skodol, A. (2019). Borderline personality disorder: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis. UptoDate. Retrieved July 26, 2020, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/borderline-personality-disorder-epidemiology-pathogenesis-clinical-features-course-assessment-and-diagnosis?search=Borderline%20Personality%20Disorder&source=search_result&selectedTitle=1~70&usage_type=default&display_rank=1.
Stahl, S. (2017). Essential psychopharmacology: The prescriber’s guide (6th ed.). Cambridge University Press.
Stovall, J. (2019). Bipolar mania and hypomania in adults: Choosing pharmacotherapy. UptoDate. Retrieved July 24, 2020, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/bipolar-mania-and-hypomania-in-adults-choosing-pharmacotherapy?sectionName=SEVERE%20MANIC%20EPISODES&search=bipolar%20type%202%20treatment&topicRef=680&anchor=H7954915&source=see_link#H991964.
Vieta, E. & Colom, F. (2019). Bipolar disorder in adults: Psychoeducation and other adjunctive maintenance psychotherapies. UptoDate. Retrieved July 25, 2020, from https://www-uptodate-com.regiscollege.idm.oclc.org/contents/bipolar-disorder-in-adults-psychoeducation-and-other-adjunctive-maintenance-psychotherapies?search=bipolar%20disorder%20cbt&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H18409684.
Wiener, C. D., Moreira, F. P., Zago, A., Souza, L. M., Branco, J. C., de Oliveira, J. F., da Silva, R. A., Portela, L. V., Lara, D. R., Jansen, K., & Oses, J. P. (2018). Mood disorder, anxiety, and suicide risk among subjects with alcohol abuse and/or dependence: A population-based study. Revista Brasileira de Psiquiatria, 40(1), 1–5. https://doi.org/10.1590/1516-4446-2016-2170.