Soap Note

Soap Note

Patient Information:

Initials: J.M.

Age: 25 years

Sex: Female

Race/Ethnicity: African American

Source and Reliability: The patient provided the history. Reliability is fair due to mood instability; however, the information was coherent, consistent, and clinically appropriate.

SUBJECTIVE:

Chief Complaint (CC)

“I feel depressed, and my moods keep changing.”

History of Present Illness (HPI)

J.M. is a 25-year-old African American female who has been referred to a psychiatrist because of persistent depressive symptoms and a change in mood. The symptoms originated several weeks ago and were gradually deteriorating. She reports continuing low mood, loss of interest in activities she once enjoyed, low energy, poor concentration, and irritability. She experiences periodic mood swings with episodes of high energy, insomnia, increased neediness, hopelessness, and depression alternately. She also reports trouble sleeping, with four to five hours a night, and denies a decreased appetite. Two months ago, she was prescribed aripiprazole 15mg/day after a stay in a psychiatric hospital but stopped taking it after three weeks because of anxiety and restlessness. She denies a significant perceived value of the medication. She has no present suicidal or homicidal thoughts but reports a passive ideation of not wanting to live in the last month: minimal delusions, paranoia, or hallucinations. Symptoms disrupt normal functioning and employment.

Current Medications

  • None currently
  • Recently discontinued aripiprazole 15 mg orally once daily after three weeks due to anxiety and restlessness.

Allergies

  • No known drug allergies
  • No known food or environmental allergies

Past Medical History (PMH)

  • Bipolar Disorder was diagnosed at age 22
  • Two prior psychiatric hospitalizations related to suicide attempts
  • No history of chronic medical conditions
  • Immunizations reported as up to date

Family History

  • Mother: History of depression
  • Father: Hypertension
  • Maternal aunt: Bipolar Disorder
  • No known family history of schizophrenia or substance use disorders

Personal and Social History

  • Lives alone
  • Currently unemployed
  • Denies tobacco use
  • Reports occasional alcohol use
  • Denies illicit drug use
  • Limited social support network
  • Reports difficulty maintaining daily routines during depressive episodes

Review of Systems (ROS)

  • General: Reports fatigue and low energy; denies fever or weight changes
  • Psychiatric: Reports depression, mood swings, anxiety, poor sleep; denies hallucinations or delusions
  • Neurologic: Denies headaches, dizziness, or seizures
  • Cardiovascular: Denies chest pain or palpitations
  • Respiratory: Denies shortness of breath or cough
  • Gastrointestinal: Reports decreased appetite; denies nausea, vomiting, or abdominal pain

OBJECTIVE:

Vital Signs

  • Blood Pressure: 118/74 mmHg
  • Heart Rate: 76 beats per minute
  • Respiratory Rate: 16 breaths per minute
  • Temperature: 98.4°F (oral)
  • Height: 5 feet 5 inches
  • Weight: 160 pounds
  • Body Mass Index (BMI): 26.6 kg/m², classified as overweight

Physical Examination

General: Alert, cooperative, and appropriately groomed. Appears to be the stated age. No acute distress observed. Oriented to person, place, time, and situation.

Head: Normocephalic and atraumatic.

Eyes: Pupils equal, round, and reactive to light. Extraocular movements intact. No scleral icterus or conjunctival injection.

Ears, Nose, Throat: External ears are normal. The nasal mucosa is pink without discharge. The oropharynx is moist without lesions.

Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. Peripheral pulses palpable and equal bilaterally.

Respiratory: Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Nonlabored breathing.

Neurologic: Cranial nerves II–XII grossly intact. Motor strength 5/5 in all extremities. Sensation intact.

Psychiatric: Mood depressed. Affect constricted but appropriate to context. Thought process is logical and goal directed. No evidence of hallucinations or delusions. Insight Limited. Judgment fair.

ASSESSMENT:

Primary Diagnosis

Bipolar I Disorder, current episode depressed

ICD-10 Code: F31.4

Pathophysiology:

Bipolar I Disorder is a chronic mood disorder, which is due to the malregulation of neurotransmitter systems, in particular, the dopamine, serotonin, and norepinephrine systems, along with the breaking of the circadian rhythm and dysfunction of the limbic system. Depressive and manic or hypomanic episodes are linked to diminished monoaminergic and amplified dopaminergic activity, respectively, and emotional regulation and arousal (Cui et al., 2024). The consequence of this neurobiological distortion is a series of mood swings, which severely affect functioning.

Clinical Rationale:

The history experienced by the patient of periodic mood elevation, reduced necessity to sleep, and increased energy, followed by major depressive episodes, confirms this diagnosis. The patient is known to have a history of bipolar disorder, various psychiatric hospitalizations associated with suicidal attempts, and a lack of response to antipsychotic monotherapy because of unbearable side effects. Present symptoms of enduring depression, mood swings, sleep disturbance, poor performance, and past manic characteristics are all reflective of Bipolar I Disorder at a depressive episode, other than unipolar.

Differential Diagnoses

  1. Major Depressive Disorder, recurrent, moderate

ICD-10 Code: F33.1

This diagnosis is considered due to the presence of persistent depressive symptoms, including low mood, anhedonia, fatigue, and impaired concentration. However, it is less likely because the patient reports clear episodes of elevated mood, decreased need for sleep, and increased energy, which are not characteristic of Major Depressive Disorder (Bains & Abdijadid, 2023).

  1. Cyclothymic Disorder

ICD-10 Code: F34.0

Cyclothymic Disorder is considered, given the history of mood fluctuations. However, this diagnosis is less likely due to the severity of the patient’s depressive episodes, history of suicide attempts, and need for psychiatric hospitalization, which exceed the symptom threshold for cyclothymia (Bielecki & Gupta, 2023).

  1. Borderline Personality Disorder

ICD-10 Code: F60.3

This diagnosis is considered due to mood instability and emotional dysregulation. However, the absence of pervasive interpersonal instability, identity disturbance, chronic feelings of emptiness, and impulsive behaviors across multiple settings makes this diagnosis less likely (Chapman et al., 2024).

PLAN:

Diagnostics and Screening

  • Administer PHQ-9 to assess the severity of depressive symptoms and establish a baseline.
  • Administer the Mood Disorder Questionnaire (MDQ) to evaluate bipolar symptom patterns further.
  • Administer GAD-7 to assess co-occurring anxiety symptoms.

Laboratory Studies

  • Complete blood count (CBC) to rule out anemia or infection contributing to fatigue.
  • Comprehensive metabolic panel (CMP) to assess liver and renal function before medication initiation.
  • Thyroid-stimulating hormone (TSH) to rule out thyroid dysfunction that may mimic mood symptoms (Seo & Lee, 2022).
  • Lipid panel and hemoglobin A1c for metabolic baseline due to planned psychotropic medication use.

Pharmacologic Treatment

  • Lamotrigine 25 mg orally once daily for 2 weeks, then increase to 50 mg daily as tolerated for mood stabilization. Titration will continue gradually per guidelines to reduce the risk of rash (Betchel et al., 2023).
  • Quetiapine 50 mg orally at bedtime for treatment of bipolar depression and to improve sleep. Dose may be titrated based on response and tolerability (Maan et al., 2023).

Nonpharmacologic Interventions

  • Referral to outpatient psychotherapy with a focus on cognitive behavioral therapy.
  • Education on sleep hygiene, including maintaining consistent sleep and wake times and limiting screen exposure before bedtime.
  • Encouraged the use of mood tracking to identify early warning signs of mood shifts.

Patient Education

  • Discussed the importance of medication adherence and not discontinuing medications without provider consultation.
  • Reviewed potential side effects of prescribed medications and when to seek medical attention.
  • Educated patient on recognizing early symptoms of mood escalation or worsening depression.
  • Advised avoidance of alcohol and illicit substances, which may worsen mood instability.

 Motivational Interviewing

The patient was worried about the side effects of medication because of her experience with aripiprazole. These considerations were confirmed, and a lower chance of causing akathisia or developing more anxiety was chosen with the help of shared decision-making to select medications. The patient had a clear narration of knowledge of the treatment plan and indicated interest in participating in medication management and therapy.

Safety Planning

  • Patient denies current suicidal or homicidal ideation.
  • Reviewed warning signs of worsening depression or suicidal thoughts.
  • Provided crisis resources and instructed to seek immediate care if symptoms escalate.

Follow-Up

  • Follow-up appointment scheduled in 2 weeks to assess medication response and symptom progression.
  • Patient instructed to contact the clinic sooner for adverse medication effects or symptom worsening.

REFLECTION

The case reveals the significance of critical evaluation and cautious choice of medications in bipolar disorder patients, especially those who have a record of drug intolerance and attempted suicide. I concur with the treatment strategy of starting a mood stabilizer and an atypical antipsychotic since it is in line with the evidence-based practice of bipolar depression. The case supported the importance of patient-centered care and shared decision-making, particularly adherence in the case of negative past experiences connected to medication. In my future practice, I would still give a priority to early education on the side effects and titration schedules as a way of minimizing premature withdrawal of treatment. Sleep hygiene, substance use avoidance, and participation in psychotherapy were identified as health promotion approaches to promote stable mood in the long term. The social determinants of health, including low social support and unemployment, also formed an essential part in the planning of the care since they can adversely affect adherence to the treatment and overall mental health outcome.

References

Bains, N., & Abdijadid, S. (2023, April 10). Major depressive Disorder. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Betchel, N. T., Fariba, K. A., & Saadabadi, A. (2023, February 13). Lamotrigine. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK470442/

Bielecki, J. E., & Gupta, V. (2023, July 17). Cyclothymic Disorder. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK557877/

Chapman, J., Jamil, R. T., Fleisher, C., & Torrico, T. J. (2024, April 20). Borderline Personality Disorder. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK430883/

Cui, L., Li, S., Wang, S., Wu, X., Liu, Y., Yu, W., Wang, Y., Tang, Y., Xia, M., & Li, B. (2024). Major depressive Disorder: hypothesis, mechanism, prevention, and treatment. Signal Transduction and Targeted Therapy, 9(1), 30. https://doi.org/10.1038/s41392-024-01738-y

Maan, J. S., Ershadi, M., Khan, I., & Saadabadi, A. (2023, August 28). Quetiapine. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK459145/

Seo, I., & Lee, Y. (2022). Usefulness of complete blood count (CBC) to assess cardiovascular and metabolic diseases in clinical settings: A Comprehensive literature review. Biomedicines, 10(11), 2697. https://doi.org/10.3390/biomedicines10112697

 

 

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Week 3 SOAP Note Question:

How does the information gathered in the Week 3 SOAP note for patient J.M. support the diagnosis of Bipolar I Disorder, and what clinical reasoning justifies the selected pharmacologic and nonpharmacologic treatment plan?