Psychiatric Evaluation Paper

Psychiatric Evaluation Paper

SOAP NOTE: Bipolar 1 (Maniac Episode)


Initials: L.M

Age: 25 years

Gender: Female

Nationality: Caucasian

Methods of Referral: Self-referral (voluntary admission)

Marital status: Single

Occupation: Student

Current Living Address: Texas

Informant: The patient and her sister

Chief Allegations:

“I feel really anxious since I was diagnosed with hypertension over a year ago, and I have not been able to stay focused.”

History of Presenting Illness

L.M walks into the emergency department with the chief allegation of feeling anxious and unable to focus for a year. Anxiety was preceded by a year ago diagnosis of hypertension, which she was advised to manage using non-pharmacological methods. She reports an increased state of worry towards no specific reference.

As a final-year university student, she reports that her anxiety levels rise, particularly as she approaches her exams, which has recently impacted her academic performance. She reports that going for a walk in the evenings helps to alleviate her anxiety. She reported having two anxiety episodes in a month a year ago, but now has at least one anxiety episode every week.

She also claims to be unable to focus while doing something. She claims to be easily distracted, with her attention drawn to unimportant or irrelevant external stimuli. She is easily distracted by the noise and movement outside of class and is unable to concentrate for 30 minutes.

She claims that this is to blame for her recent poor academic performance. She also claims to have had an expansive mood for the past week, which was punctuated by bouts of irritability. Her sister is concerned about her recent sexual perversion, as she has had four boyfriends in the last month and admits to engaging in sexual activities more frequently. She claims to have no family history of mental illness.

Treatment and Drug History: No prescribed treatments. She manages her hypertension through non-pharmacological means, including physical activity, the DASH diet, and reduction of risk behaviors (reduction of alcohol consumption)

Past Psychiatric History: This is her first time visiting a mental health clinic. No previous history of psychiatric illness. No history of mental disorders in the family

Past Medical/Psychiatric History:

Hypertensive since a year ago. No past history of surgical condition/procedures. No known food and drug allergies

Menstrual & Obstetric History: Regular menses every 28 days, a light flow, using 2-3 pads/day, 3-5 days of flow. No history of contraceptive use. No previous cervical cancer screening. She is a Para 0+0.

Family History:

Father: James; Alive; 63 years of age; Businessman; healthy

Mother: Anne; Alive; 59 years; Business lady; healthy

She is the second born with two other siblings, as listed below

First born: John; Alive; male; 28 years; accountant; he is an alcoholic binge drinker

Second born: Patient

Third born:  Mercy; alive; female; 16 years; high school; allergic rhinitis

Recent family event: 25th of December, 2021-Annual family gathering

Social/Personal History:

Education: She is a finalist at an accounting school, reports to enjoy school; however, her recent anxiety and inability to concentrate are threatening her performance

Intimate relationships (psychosexual history): She has had a total of six boyfriends since the age of 18. She has had intimate encounters with four boyfriends in the last month. Her sister claims that L.M has recently become obsessed with sexual indiscretions. There is no history of abuse in her previous relationships.

Family and social support: Receives adequate support from her family. her parents pay her school fee and daily upkeep

Religion: Christian

Living arrangements: Stays with her parents and commutes daily to school.

Hobbies: Reading novels

Substance use: Occasionally drinks alcohol (beer), at most 3 bottles in one sitting, once a month

Forensic history: she has had no encounter with authority figures

Premorbid personality: Friendly. She is still as friendly as she used to be in the premorbid period.

Physical Examination

On examination, she is a young Caucasian female, well-groomed and kempt; she is fidgeting, not in any apparent respiratory distress. She has no pallor, no jaundice, no cyanosis, no edema, and no lymphadenopathy. Her vital signs are as follows:

BP: 131/88 mmHg

HR: 84 beats/minute

RR: 21 breaths/minute

SPO2: 97%

Temperature: 98.6 F

Systematic Examination:

CVS: Normoactive precordium. S1 and S2 heart sounds are present. No added heart sounds

All other systems are essentially normal

Mental State Exam

Appearance and behavior: A 25-year-old female Caucasian female, well-groomed, well-kempt, fidgeting, seated slouched on the chair. She does not maintain seamless eye contact and is often distracted by the movements in and out of the examination room. Her face is drenched in sweat.

Speech: she is over-talkative, articulates clearly and loud, has a pressured speech, and answers the questions without hesitancy.

Mood and Affect: She has a labile mood and a stable affect

Thought content and process: In her thought content, she is anxious with no specific referent, and has a flight of ideas in her thought process.

Perception abnormalities: She has no perception disturbances

Cognition: she is conscious, and oriented to time, place, and person, has intact short-term, long-term, and remote memory

Judgment: Appropriate

Abstract: Appropriate

Insight: She has a good insight, and recognizes that she is sick and requires mental health treatment

Diagnostic Formulation

L.M, a 25-year-old Caucasian female client, comes in with a one-year history of anxiety and difficulty concentrating. She also has an expansive mood and engages in sexual indiscretions excessively. She reports poor academic performance due to her anxiety and inability to concentrate.

A year before the symptoms, she was diagnosed with hypertension. She has no history of psychiatric illness or treatment, nor does she have a family history of mental disorders. On the mental state exam, she exhibits anxiety-related behaviors such as fidgeting, slouching in her chair, and drenching sweat on her face. She is overly talkative, and has pressured speech and flight of ideas.

Multiaxial Diagnosis

Axis 1: Bipolar 1 (Maniac Episode) with a differential diagnosis of generalized anxiety disorder

Manic Phase of Bipolar Disorder: According to the DSM V diagnostic criteria for mental disorders, the diagnosis of manic episode requires (a) a distinct period of abnormally and persistently expansive or elated or irritable mood lasting at least one week (Jain & Mitra., 2022). Evidently, L.M complains of expansive mood in the past one week, alternated with episodes of irritability.

In criteria (b), during the period of the mood disturbance, three or more of the following must be present: inflated self-esteem or grandiosity, decreased need for sleep (e.g., feels rested after only 3 hours of sleep), more talkative than usual or pressure to keep talking, flight of ideas or subjective experience that thoughts are racing, distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation, excessive involvement in pleasurable activities that have a high potential for painful consequences e .g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments (Kessing et al., 2021).

In the history, the L. M’s sister recounts that L.M has had several sexual encounters with multiple boyfriends in the past one month, is talkative, and is easily distractible, provisions which have been stated in DSM V criteria for a manic episode.

Generalized Anxiety Disorder: This is a possible differential diagnosis, and the DSM V criteria include (a) excessive worry that occurs on more days than not for at least 6 months, (b) the individual finds it difficult to control the worry, and (c) the anxiety is associated with three or more of the following for at least 6 months: restlessness, easily fatigued, irritability, muscle tension, difficulty concentrating, and sleep disturbance. (d) the anxiety results in significant occupational, social, or other considerable impairment, and (e) the anxiety is not explained by substance abuse or any other medical condition (Jain & Mitra., 2022).

L.M reports that she has been anxious for the past year, has difficulty concentrating, and is irritable. Further, she is restless, as evidenced by her fidgeting and slouching on the chair during the examination.

Axis II: No personality or developmental disorder

Axis III: Hypertension

Axis IV: Psychosocial stressors: She is a finalist in an accounting program and takes difficult exams on a regular basis.


  1. Complete blood count
  2. Urea and electrolytes
  3. Blood pressure monitoring
  4. Random blood sugar levels

Pharmacologic Treatment

  1. Quetiapine 100 mg at bedtime
  2. Lamotrigine 25 mg PO daily for two weeks, then 50 mg PO daily for two weeks, then 100mg PO daily for 1 week, then double the dose weekly to maintenance at 200 mg/day PO (Baldessarini et al., 2019)
  3. Lorazepam 1 mg prn BID for her anxiety

Non-Pharmacological Management

  1. Regular moderate aerobic physical exercises at least 10 minutes/week
  2. Continue the DASH diet
  3. Cease consumption of alcohol


Observe medication adherence. Continue to follow the non-pharmacological recommendations. If she gains weight, she should discontinue Quetiapine after reaching the maximum maintenance dose of Lamotrigine. Quetiapine is a second-generation antipsychotic medication that has been linked to metabolic side effects such as obesity, hyperglycemia, hypertension, and hypertriglyceridemia (Tandon et al., 2020).


Monthly follow-up


Baldessarini, R. J., Tondo, L., & Vázquez, G. H. (2019). Pharmacological treatment of adult bipolar disorder. Molecular Psychiatry24(2), 198–217.

Jain, A., & Mitra., P. (2022). Bipolar Affective Disorder. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from:

Kessing, L. V., González-Pinto, A., Fagiolini, A., Bechdolf, A., Reif, A., Yildiz, A., Etain, B., Henry, C., Severus, E., Reininghaus, E. Z., Morken, G., Goodwin, G. M., Scott, J., Geddes, J. R., Rietschel, M., Landén, M., Manchia, M., Bauer, M., Martinez-Cengotitabengoa, M., … Vieta, E. (2021). DSM-5 and ICD-11 criteria for bipolar disorder: Implications for the prevalence of bipolar disorder and validity of the diagnosis – A narrative review from the ECNP bipolar disorders network. European Neuropsychopharmacology: The Journal of the European College of Neuropsychopharmacology47, 54–61.

Tandon, R., Lenderking, W. R., Weiss, C., Shalhoub, H., Barbosa, C. D., Chen, J., Greene, M., Meehan, S. R., Duvold, L. B., Arango, C., Agid, O., & Castle, D. (2020). The impact on functioning of second-generation antipsychotic medication side effects for patients with schizophrenia: a worldwide, cross-sectional, web-based survey. Annals of General Psychiatry19(1), 42.

Psychiatric Evaluation Paper Instructions

Create a Comprehensive Psychiatric Evaluation Note on this patient using the template provided in the Learning Resources. There is also a completed template provided as an exemplar and guide.

  • Include at least five scholarly resources to support your assessment and diagnostic reasoning.
  •  Include subjective and objective data; assessment from most recent mental status exam; current psychiatric diagnosis including differentials that were ruled out; current psychotherapeutic plan (include one health promotion activity and one patient education strategy you provided); and patient progress toward treatment goals.
  • Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What was the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
  • Objective: What observations did you make during the psychiatric assessment?
  • Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses in order of highest to lowest priority and explain why you chose them. What was your primary diagnosis and why? Describe how your primary diagnosis aligns with DSM-5-TR diagnostic criteria and is supported by the patient’s symptoms.
  • Plan: Describe your treatment modality and your plan for psychotherapy. Explain the principles of psychotherapy that underline your chosen treatment plan to support your rationale for the chosen psychotherapy framework. What were your follow-up plan and parameters? What referrals would you make or recommend as a result of this psychotherapy session?
  • Reflection notes: What would you do differently in a similar patient evaluation? Reflect on one social determinant of health according to the HealthyPeople 2030 (you will need to research) as applied to this case in the realm of psychiatry and mental health. As a future advanced provider, what are one health promotion activity and one patient education consideration for this patient for improving health disparities and inequities in the realm of psychiatry and mental health? Demonstrate your critical thinking.