Soap Note on Patient with Bipolar Disorder

SOAP NOTE ON BIPOLAR

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Soap Note on Patient with Bipolar Disorder

Identification\ Problem Recognition Patient initial M.A Nationality Saudi Problem Statement
Age 23 Source of information Patient   Easy fatigability for few weeks and dizziness
Sex F Diagnosis Iron Deficiency Anemia
SUBJECTIVE DATA HPI  NM is a 35-year-old female, who has recently dropped from college after two suicidal attempts and alcohol intoxication, in which she was taken to the outpatient department. “I feel like everything is falling, I just want to die. Let me go.” She reports. She had changed her course thrice, from Nursing to sociology, and last week changed to theology. She reports to have reduced hours of sleep due to racing thoughts. She has lost her social networks, with no interest in discussions, meetings and attending classes. She has dramatically lost weight, which she relates with her lost appetite and lack of energy to prepare meals. Her drinking behaviours have recently increased, with intent to lose connection with reality. She has severally engaged in risky behaviours such as jumping from a tree. Her sexual activity is out of control.
PMH She is known bipolar for three years. She however reports to have flushed off her drugs, after they seemed not to help any more. She also discontinued her therapy sessions for lack of interest.
Surgical History No previous surgeries reported
Family History -Mother: no history of any chronic illness-Father: substance-induced psychosis for ten years (died three years ago)- A mother of three; 2 males and one female. All healthy and well.
Social History NM is a college student pursuing theology. She has reports of alcohol intoxication both in depressive and maniac phases. She denies the use of bhang or any other hard drug. She lives alone close to the college.
Allergies She reports no known food or drug allergies for drugs.
MEDS. Previously put on;Lamotrigine 50mg oral, BD daily.Olanzapine 5mg oral, OD daily.
Immunization The patient immunization schedule is up-to-date
ROS HEENT Patient denies any disturbed vision, hearing or breathing. She denies painful swallowing or head injury. She however reports regular headaches.
RESP. Patient denies any disturbed breathing, pain in the chest or shortness of breath.
CV Patient denies heart arrhythmias, painful chest on exertion or at rest.
GI\GU Patient denies vomiting, diarrhoea or constipation. She however reports reduced appetite and weight loss.
MSK Patient denies muscle pain, joint pains or reduced range of motion.
SKIN Patient denies any skin cuts, growths or signs of infection. She however has scars from previous injuries due to falls.
Mental Patient is oriented to time, place and person, and has insight. She reports to have lived with bipolar for three years after being admitted with depression.
OBJECTIVE DATA

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PHYSICAL ASSESSMENT

V\S T:36.3c        RR: 18 bpm       BP :108/64mmHgHT:157 cm    WT:54 kg            BMI:19.22
General Appearance She is alert, unkempt, athletic in nature and dull. Her dressing is heavy despite the hot weather.
HEENT Hair: short, clean but unkempt. Evenly distributed on the scalp.Eyes: symmetrical visual acuity, no discharge, cloudy or plaques in the eyes. No implants or fixtures. White conjunctiva, with present central and peripheral visual fields.Mouth and throat: dry mucous membranes, stained teeth, and missing incisor. No bleeding observed. Tonsils not palpable, jugular distension not visible.
Neuro. Cranial nerves showed optimal functioning. The patient exhibited optimal gait and balance while pacing around the room.
CV Patient had no oedema on lower and upper limbs. His heart rate showed no murmurs or arrhythmias.
RESP. Clear lung sounds, no murmurs or chest pains. Respiratory rate was optimal. Chest movement was symmetrical with no sign of obstruction.
GI \ GU Not examined
Skin Normal pigmentation and colour.
Musculoskeletal Not examined
Mental Alert, oriented, and has insight. She has a blunt affect, has mutism and inappropriately dressed.
DIAGNOSTIC TESTS -MSA: Mutism, suicidal attempts and ideations, disturbed sleep, lack of appetite, disorganized plan of activities and lost interest in social interactions. Episodes of reckless drinking, risky behaviours, excessive spending and self-injuries.No lab test was ordered.

Head CT scan: No indication of haemorrhage, oedema or growths.

DIFFRENTIAL DIAGNOSIS Diagnosis Rationale
Substance induced psychosis SIP produces hallucinations, delusions and disorganization, among clients with a history of substance abuse. NM has history of alcohol abuse. Her MSA however misses to indicate any form of hallucination or delusion.
Head trauma Closed head trauma could lead to haemorrhages and oedema hence applying pressure on functional brain. This in turn blocks nervous impulse transmission causing persistent confusion. However, NM has no history of head injury, and her CT scan was clear, hence ruling out head trauma.
hyperthyroidism It presents with increased skeletal muscle activity hence euphoria (Al Eidan et al., 2018). In addition, the patient has a high metabolic rate resulting to heat intolerance, hyperactivity and palpitations. NM has lacks cardiovascular complications, her temperatures have been consistently optimal and thyroid palpation was undistended.
Plan Nonpharmacological treatment CBT: Cognitive behavioural therapy responds to mood changes that are subject to pessimistic way of thinking, as it is for depression and bipolar. CBT therapists educate the patient further about the diagnosis, support them in goal setting, and teach them on behavioural skills (Jelen & Young, 2020). Bipolar patients learn how to identify depressive and mania signs, and how to handle them. The therapist also helps the client understand need for compliance, and identify side effects.Family-focused therapy: It is founded on need to avoid relapse, and address criticism and hostility by the caregiver. The client and direct caregiver(s) attend a series of sessions on psycho-education, communication skills and problem solving skills. During these sessions, the client is the ’expert’, who leads the sessions by discussing his/her symptoms in presence of the caregivers, relatives and siblings (Miklowitz & Chung, 2018).
Pharmacological Treatment DRUG General Considerations
Symbyax (Olanzapine 6mg/fluoxetine 25mg) 1 Tab OD every evening. – The combination improves depressive symptoms with a greater effectiveness than that of olanzapine as a monotherapy.- side effect includes nausea, vomiting, enhanced sex drive and weight gain.- Medication is taken after meals in the evening.
Carbamazepinene (CBZ) 100mg BD daily administered orally (Cuéllar-Barboza et al, 2020). – It produces an inhibitory effect on GABA neurotransmitters by blocking the calcium channels of glutamate receptors.Side effects are also including nausea, vomiting, dry mouth, swollen tongue and drowsiness.
Surgery/Other Procedures None
Follow Up NM is expected to attend therapy sessions booked with her psychologist. Follow-up clinics after every two weeks are also indicated, to refill the drugs and review the doses accordingly. Time to time assessment of serum drug levels is also indicated to avoid occurrence of toxicity. The social worker is also needed to review the environment of NM while at home, to assure absence of relapse triggers.
Education The patient is educated on disease management and pathology, and need to comply with the new medication line. NM is also educated on need to revisit the hospital if signs of mania or depression reappear before the next clinic.Additional education includes:-       Taking up therapy sessions to support behavioural change

–       The side effects of the medication including extra-pyramidal effects.

Referral NM is to be referred to a therapist for continued counseling sessions. Counseling will stimulate and enforce her insight and taking up care of self even during the attacks.
Learning Resources Soap Note on Patient with Bipolar Disorder Al Eidan, E., Ur Rahman, S., Al Qahtani, S., Al Farhan, A. I., & Abdulmajeed, I. (2018). Prevalence of subclinical hypothyroidism in adults visiting primary health-care setting in Riyadh. Journal of Community Hospital Internal Medicine Perspectives, 8(1), 11–15. doi:10.1080/20009666.2017.1422672Cuéllar-Barboza, A.B., McElroy, S.L., Veldic, M. (2020). Potential pharmacogenomic targets in bipolar disorder: considerations for current testing and the development of decision support tools to individualize treatment selection. International Journal of Bipolar Disorders, 8(23), 1638. https://doi.org/10.1186/s40345-020-00184-3Gitlin M. J. (2018). Antidepressants in bipolar depression: an enduring controversy. International Journal of Bipolar Disorders6(1), 25. https://doi.org/10.1186/s40345-018-0133-9

Miklowitz, D. J., & Chung, B. (2016). Family-Focused Therapy for Bipolar Disorder: Reflections on 30 Years of Research. Family Process55(3), 483–499. https://doi.org/10.1111/famp.12237