Bipolar Disorder Discussion Paper
InPlace Logbook – Session 4
1) Activity
Activity Category: Duration of Patient Encounter
Activity Category:
Activity Time:
2) Patient Demographics
Age (in years):
Gender:
Insurance:
Race:
Referral: No Referral
3) Clinical Information
Reason for Visit:
Social problems addressed: Bipolar Disorder Discussion Paper
Medication(s):
Procedures:
Low complexity
Type of Decision Making:
Patient visit was completed via telemedicine:
Chief Complaint: “This appointment was the decision of my parents as a result of the difficulties which I have been going through at school.”
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4) Industry Code
Industry Code Name: ICD-10
Select Industry Code:
S
HPI: The patient is a 29-year-old Caucasian male who presents to the clinic after his parents scheduled an appointment for him since he was having academic difficulties. He is currently doing theoretical physics and advanced calculus in school, and that the classes are riddles to him because he forgets when he thinks he has grasped it. He claims that his college roommate has installed a microwave in their shared space and is using it to eavesdrop on him. He reports that he has been losing weight and becoming less interested in the things he used to enjoy, as well as hearing voices that inform him that he is being watched. He also reports that he has not been staying in touch with his friends, has not been grooming, and only sleeps for around four hours a night on average.
O
Vitals: Temp: 37.2 C BP: 122/79 RR: 17 HR: 88 Ht: 5’8 Wt: 185 lbs
ROS: No complaints.
Current medications: None
Labs: Brain CT scan: Normal
Mental status exam:
Patient appears unkempt with disheveled dressing. He maintains good eye contact. He had an uneasy expression on his face, he had shivers, and he was wandering about the room, making it impossible to establish a relationship with him. He has an angry mood with a flat affect. He speaks slowly but with less content and fluidity, he has odd hallucinations, illogical thinking, and a lack of coherent thinking. Although his comprehension has been impaired, he has a history of hearing voices, and he reacted to some of them during the evaluation. His orientation is intact, although he has little insight into the nature of his condition Bipolar Disorder Discussion Paper.
A
DSM5 Principal Dx: Schizophrenia F20. 9.
Differential DDx:
- Bipolar disorder F31
Rational: patients with bipolar disorder often experience delusions and hallucinations.
- Schizoaffective disorder F25. 9
Rational: patients with bipolar disorder often experience delusions and hallucinations.
P
- Start trial of Clozapine 12.5 mg once daily orally
Rational: Clozapine has been found to improve Schizophrenia symptoms and overall functioning.
- Start cognitive behavioral therapy
Rational: teaches a person to modify beliefs or behaviors that may be leading to negative emotions.
- Patient education
- Patient educated on importance of being compliant with the medication regimen
- Patient educated to maintain a balanced diet and engage in regular physical activity
- Patient educated to find a support group near his home and join one
- Patient educated on the importance of attending all the follow-up visits
- Patient to follow up in 2 weeks to evaluate treatment.
SOAP 2
In Place Logbook – Session 4
1) Activity
Activity Category: Duration of Patient Encounter
Activity Category:
Activity Time:
2) Patient Demographics
Age (in years): Bipolar Disorder Discussion Paper
Gender:
Insurance:
Race:
Referral: No Referral
3) Clinical Information
Reason for Visit:
Social problems addressed:
Medication(s):
Procedures:
Low complexity
Type of Decision Making:
Patient visit was completed via telemedicine:
Chief Complaint: “It seems that my son can’t concentrate when he makes his homework. His teacher complains that he is not able to sit still during class lectures.”
4) Industry Code
Industry Code Name: ICD-10
Select Industry Code:
S
HPI: The patient is a 7-year old African American male who is brought to the office by his mother who reports that the boy makes careless mistakes in school work and other activities at home. She adds that the boy has also been having difficulties paying attention to activities that he is involved in, does not seem to listen when spoken to and does not follow through with instructions. She says the his teacher has reported these symptoms two times previously and she has decided to bring him to hospital to be checked since he has tried to talk to the child and even punish the child but he does seem to change his unruly behaviors. Mother says that the boy is thought of by other people to be having. Mother also adds that the child has been having these symptoms since he was 2 years and she thought it was part of his developmental milestones but since the symptoms have been persistent, she thinks her son has a problem Bipolar Disorder Discussion Paper.
O
Vitals: Temp: 37.2 C BP: 122/79 RR: 19 HR: 96 Ht: 120cm Wt: 46 lbs
ROS: No complaints.
Current medications: None
Labs: None
Mental status exam:
Gait and station: WNL steady walk
Appearance: WNL appropriately dressed
Behavior: hyperactive
Mood: irritable
Affect: flat
Though process: logical/coherent
Though content: WNL
Perceptual: WNL
Cognition: intact
Attention and concentration: limited attention span
A
DSM5 Principal Dx: Attention-deficit/hyperactivity disorder F90. 0
Differential DDx:
- Learning/language disorder F80.9
Rational: patients with this disorder exhibit lack of attention to activities
- Oppositional defiant disorder F91. 3
Rational: patients with this disorder display hostile behaviors
P
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- Start trial of Methylphenidate 20 mg PO 1tab daily before breakfast
Rational: Methylphenidate has been found to help with hyperactivity and impulsive behavior, and allows patients to concentrate better
- Patient education
- Parent educated on the symptoms, typical cause of the disorder and treatment options
- Parent educated to support and advocacy organizations for children with ADHD
- Parent educated on available online resources on ADHD
- Parent educated on the importance of attending all the follow-up visits
- Patient to follow up in 4 weeks to evaluate treatment.
SOAP 3
InPlace Logbook – Session 4
1) Activity
Activity Category: Duration of Patient Encounter
Activity Category:
Activity Time:
2) Patient Demographics
Age (in years):
Gender:
Insurance:
Race:
Referral: No Referral
3) Clinical Information
Reason for Visit:
Social problems addressed: Bipolar Disorder Discussion Paper
Medication(s):
Procedures:
Low complexity
Type of Decision Making:
Patient visit was completed via telemedicine:
Chief Complaint: “I was referred here by my dad.”
4) Industry Code
Industry Code Name: ICD-10
Select Industry Code:
S
HPI: Patient is a 15-year-old Caucasian male who came to the clinic in his father’s company after his father referred him for ongoing mental health services. His father reported that he has a history of previously following the wrong crowd of friends, which landed him in legal problems. The father also reported that he has been doing very poorly in his academics, where he did not complete his school work and did not care about school. He has a history of inattentiveness, poor anger control, non-conforming, refusal to follow the rules, poor concentration, and stealing.
O
Vitals: Temp: 36.9 C BP: 122/79 RR: 19 HR: 96 Ht: 5’2 Wt: 87 lbs
ROS: No complaints.
Current medications: None
Labs: None
Mental status exam:
Patient appears well-nourished and appropriately dressed to the weather and well-kempt. He relates well; his manner is pleasant, his speech is normal with good articulation, fluent, and normal in rate and tone. His mood is euthymic, the affect is appropriate, he does not have ideations of homicide/suicide, and he is not paranoid. He does not have delusions; his stream of thoughts is logical, coherent, and goal-directed. He is cooperative, maintains eye contact, his intelligence is average, and his memory is intact. He is oriented to time, person, and place, his insight of the condition is fair, but his judgment is impaired.
A
DSM5 Principal Dx: Oppositional defiant disorder F91. 3
Differential DDx:
- Conduct disorder F91. 9
Rational: patients with this disorder exhibit refusal to follow the rules and poor concentration
- Attention-deficit/hyperactivity disorder F90. 0
Rational: patients with this disorder display inattentiveness.
P
- Start individual and family therapy.
Rational: This will help build positive family interactions and to manage problematic behaviors
- Patient education
- Patient educated to adhere to the treatment regimen
- Parent educated to support and advocacy organizations for children with ODD
- Parent educated on available online resources on ODD
- Patient educated on the importance of attending all the follow-up visits
- Patient to follow up in 4 weeks to evaluate treatment Bipolar Disorder Discussion Paper.
SOAP 4
In Place Logbook – Session 4
1) Activity
Activity Category: Duration of Patient Encounter
Activity Category:
Activity Time:
2) Patient Demographics
Age (in years):
Gender:
Insurance:
Race:
Referral: No Referral
3) Clinical Information
Reason for Visit:
Social problems addressed:
Medication(s):
Procedures:
Low complexity
Type of Decision Making:
Patient visit was completed via telemedicine:
Chief Complaint: “I have breast cancer, and thus I am going to die soon.”
4) Industry Code
Industry Code Name: ICD-10
Select Industry Code: Bipolar Disorder Discussion Paper
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S
HPI: Patient is a 20-year-old Afro-Asian female who came to the clinic complaining that she has breast cancer, making her worried since it will kill her soon. She reported that she “just knows” she has breast cancer. She also reported that she has been using google a lot to research her symptoms and has found that she has most of the signs and symptoms of breast cancer. She reported that she has been having left breast swelling and nipple pain, but they are not there all the time. She reported that the symptoms have been present for the last 10 months, bothering her and affecting her life. She reported that she once went to a hospital where examinations and tests were done, but they were normal. She reported that she was reassured, but she believes that the healthcare provider who attended her was ignoring her, and the test results were also not reassuring her.
O
Vitals: Temp: 36.9 C BP: 122/79 RR: 19 HR: 96 Ht: 5’4 Wt: 145 lbs
ROS: No complaints.
Current medications: None
Labs: Breast ultrasound: Normal CBC: Normal Illness Attitude Scale: 50 Health Anxiety Inventory: 69
Mental status exam:
Patient is in good nutritional status, dressed appropriately, is well-kempt, and has a normal gait. She is cooperative to the examiner; she is not reassured easily, her eye contact is intense, and her eyes are wide open. Her speech is strained, her voice is trembling, but it is in the right tone, she frequently shifts her posture, her mood is depressed, and she has an anxious affect which has restricted fluctuations and is limited in depth. She responds to questions well but relapses to a concern that she had expressed previously despite being reassured. Her thought content is preoccupied with her being ill; however, she is attentive, alert, and oriented fully to place, time, and person. She has an intact short-and-long-term memory, she recognizes bodily sensations, but she lacks insight into her underlying psychological concerns Bipolar Disorder Discussion Paper.
A
DSM5 Principal Dx: Illness Anxiety Disorder F41. 9
Differential DDx:
- Somatization disorder F45. 0
Rational: patients with this disorder exhibit excessive anxiety over their health
- Body dysmorphic disorder 22
Rational: patients with this disorder are preoccupied with an imagined physical defect
P
- Start trial of Sertraline 25 mg once daily
- Start CBT
Rational: CBT helps patients find different ways to manage their worries other than excessive medical testing or avoidance of medical care
- Patient education
- Patient educated about her condition
- Patient educated to adhere to the treatment regimen
- Patient educated on the importance of eating a healthy diet, and exercising regularly
- Patient educated on the importance of attending all the follow-up visits
- Patient to follow up in 4 weeks to evaluate treatment.
SOAP 5
InPlace Logbook – Session 4
1) Activity
Activity Category: Duration of Patient Encounter
Activity Category:
Activity Time:
2) Patient Demographics
Age (in years):
Gender:
Insurance:
Race:
Referral: No Referral
3) Clinical Information
Reason for Visit:
Social problems addressed:
Medication(s):
Procedures:
Low complexity
Type of Decision Making:
Patient visit was completed via telemedicine:
Chief Complaint: “I have been hearing some voices talking to me.”
4) Industry Code
Industry Code Name: ICD-10
Select Industry Code: Bipolar Disorder Discussion Paper
S
HPI: Patient is a 62-year-old Hispanic male who presented to the clinic accompanied by his wife and complaining of sometimes hearing voices. His wife reported that he was discharged from the hospital two weeks ago for a psychotic breakdown. She reported that sometimes he has been acting strangely lately where sometimes he is withdrawn to himself while other times, he is irritable and throws things in the house, which makes the children scared of him. He reported that he has been feeling depressed and reports that sometimes he wants to be alone without being disturbed by family members, but no one seems to understand him. He reported that the occasional auditory hallucinations he has been hearing are not commanding in nature.
O
Vitals: Temp: 37.1 C BP: 106/69 RR: 15 HR: 94 Ht: 5’7 Wt: 176 lbs
ROS: No complaints.
Current medications: None
Labs: None
Mental status exam:
Patient is guarded and withdrawn; he is in good nutritional status, is not dressed appropriately, is poorly groomed, and has a normal gait. He is not cooperative, has poor eye contact, and has poverty of speech where he only responds in one or two words but is normal in rate, rhythm, and volume. His mood is depressed; he has a flat affect, passive auditory hallucinations that are not commanding on and off, and a disorganized thought process. He also has poor insight and judgment; he has normal cranial nerves that are all intact, alert, and oriented ×3. Bipolar Disorder Discussion Paper
A
DSM5 Principal Dx: Schizophrenia F20. 9.
Differential DDx:
- Bipolar disorder F31
Rational: patients with bipolar disorder often experience delusions and hallucinations.
- Schizoaffective disorder F25. 9
Rational: patients with bipolar disorder often experience delusions and hallucinations.
P
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- Start trial of Clozapine 12.5 mg once daily orally
Rational: Clozapine has been found to improve Schizophrenia symptoms and overall functioning.
- Start cognitive behavioral therapy
Rational: teaches a person to modify beliefs or behaviors that may be leading to negative emotions.
- Patient education
- Patient educated on importance of being compliant with the medication regimen
- Patient educated to maintain a balanced diet and engage in regular physical activity
- Patient educated to find a support group near his home and join one
- Patient educated on the importance of attending all the follow-up visits
- Patient to follow up in 2 weeks to evaluate treatment.
What is highlighted below, please copy and paste with each SOAP note, I will fill it out. Thanks!
No need to double space.
In Place Logbook – Session 4
1) Activity
Activity Category: Duration of Patient Encounter
Activity Category:
Activity Time: 1.5 hrs.
2) Patient Demographics
Age (in years): 31 Bipolar Disorder Discussion Paper
Gender: Male
Insurance: Private Insurance
Race: White
Referral: No Referral
3) Clinical Information
Reason for Visit: First visit
Social problems addressed: Emotional
Medication(s): None
Procedures: N/A
Low complexity
Type of Decision Making: Moderate complexity,
Patient visit was completed via telemedicine: No was not telemedicine
Chief Complaint: “I have been starting to get nightmares again and I am also excessively anxious.”
4) Industry Code
Industry Code Name: ICD-10
Select Industry Code: F43.1 Post-traumatic stress disorder
5) SOAP Notes
S
HPI: The patient is a 31-year-old Hispanic male that presents at the office as a new visit. He reports that he was previously diagnosed with PTSD and depression by another provider and used to take medication for it but he stopped due to S/E. He states he doesn’t remember which meds he was on. He said that he had been in Iraq for three deployments, the most recent of which was three months ago, but that he was the sole survivor of an ambush that occurred while their convoy was traveling. He had been released from the marine unit two months earlier. Since that time, he has been beating himself up over what transpired and is certain that he had the ability to prevent it and rescue them. On the other hand, he does not like discussing the particulars of that episode, and he claims that he is not prepared to speak to anybody under any circumstances. He has also been having trouble sleeping, and when he does fall asleep, he has been experiencing vivid dreams and nightmares. He adds that this has happened in the past and it’s been happening often recently. According to him, he had a recurring dream in which he saw the place where they had been ambushed together with the dead corpses of his fellow soldiers. He claims that, as a result of his highly aggressive and irritated nature, he has been getting into fights more often than usual. He states that he has attempted to commit suicide a few years ago. His mood has been anxious. Sleep is poor, appetite is normal. He admits to drinking 2-3 alcoholic beverages a week. He does not smoke and used to smoke marihuana in the past. No current S/I or H/I ideations Bipolar Disorder Discussion Paper.
O
Vitals: Temp: 37.2 C BP: 122/79 RR: 17 HR: 88 Ht: 5’8 Wt: 185 lbs
ROS: No complaints.
Current medications: None
Labs: CBS, CMP, Tox. screen
PHQ9: 2
Mental status exam:
Patient appears appropriately dressed, well-groomed. He struggles to maintain eye contact, he is calm and composed when answering questions, he has poor concentration, but he was cooperative. His speech is comprehensible, and it is in the normal rhythm, rate, volume and the variation in tone is also normal, and his mood is self-reported to be anxious and his affect is preoccupied. He was noted to have a decreased rage of positive emotions; he had amnesia for some parts of the traumatic events, no suicide ideations or delusions present. He has a goal-oriented thought process, and has a sense of self-blame, and he is aware of his problem and is willing to get help Bipolar Disorder Discussion Paper.
A
DSM5 Principal Dx: Post-traumatic stress disorder F43.1
DDx:
- Acute stress disorder F43.
Rational: patients with PTSD often experience sleep disturbances and nightmares.
- Major depressive disorder F33.1
Rational: Patients with depression often experience suicide ideation.
- Anxiety disorder F41.9
Rational: Patients with anxiety disorder often get repeated flashbacks of traumatic experiences Bipolar Disorder Discussion Paper
O
- Start trial of Sertraline 25 mg daily orally,
- Start trial of Prazosin 1 mg orally at bedtime
Rational: Sertraline and Prazosin have been found to improve PTSD symptoms and overall functioning.
- Start trauma-focused cognitive behavioral therapy
Rational: trauma-focused cognitive behavioral therapy improves coping techniques so that a person can better react to reminders of the traumatic experience and the emotions connected with it. Bipolar Disorder Discussion Paper
- Patient education
- Patient educated on importance of being compliant with the medication regimen
- Patient educated to practice self-calming techniques
- Patient educated to find a support group near his home and join one
- Pt educated on the importance of attending all the follow-up visits
- Patient to follow up in 3 weeks to evaluate symptoms.
SOAP notes should be for patients being seeing in a regular in-office provider/family doctor. No hospitalizations or emergencies. No referred patients from another primary provider. No acute cases or patients being taken in by police. They should be mostly first visit patients or follow-up appointments to see if meds are working. ***I attached an example of a SOAP you wrote, I just changed it some. ***Also, for the MSE (Mental Status Exam) please alternate between list style and narrative style. Please let me know if you have any questions! Thank you! Bipolar Disorder Discussion Paper