2 bipolar disorder

45 63 166 BMI
22.86 kg/m2
A/D : 14 2555 D/C (home visit) : 25 2555

CC: 1

PI : - .. 2547



major depressive disorder fluoxetine (20) 2X1 pc,
lorazepam (1) 1 X 1 hs

.. 2553
2


2 4

bipolar I disorder : manic episode
venlafaxine (150)
1X1 , Lithium(300) 1 X 2 pc, perphenazine (8) 1 X 2 pc,
clonazepam (2) 1 X 1 hs, trihexyphenidyl (2) 1 X 1 hs

.. 2555 (1
)



- 1

PMH: Bipolar disorder (
2553

major depressive disorder 2547),

,
Medication history

- Venlafaxine (Effexor) 75 mg 1 X 1 pc
- Venlafaxine (Effexor) 150 mg 1 X 1 pc
- Trazodone50mg1X1hs
- Amlodipine 10 mg 1 X 1 pc
- Simvastatin 20 mg 1 X 1 hs
Allergy: NKDA
FH&SH:

Vital sign

Physical examination: psychiatric examination

Speech: normal rhythm-rate-volume
Mood: depressed mood
Affect: blunted affect
Though: coherent, relevant, no delusion
orientation: oriented to time place person
Perception: no hallucination
Insight: intellectual
Judgement: fair

 Attention: distractibility

Problem list
1. Bipolar I disorder : depressive episode
2. Hypertension
3. dyslipidemia
SOAP problem list 1
SOAP Note
Problem list : Bipolar I disorder : Depressive episode
Subjective data
54
A/D: 14 2555 D/C (home visit): 25 2555
CC : 1

PI : - .. 2547



major depressive disorder
.. 2555 (1
)

- 1

PMH: Bipolar disorder (
2553

major depressive disorder 2547),

,
FH&SH:

ALL : NKDA
Objective data
Medication history
.. 2547 : fluoxetine (20) 2X1 pc, lorazepam (1) 1 X 1 hs
..2553 : venlafaxine (150) 1X1 , Lithium(300) 1 X 2 pc,
perphenazine (8) 1 X 2 pc, clonazepam (2) 1 X 1 hs,
trihexyphenidyl (2) 1 X 1

- Venlafaxine (Effexor) 75 mg 1 X 1 pc
- Venlafaxine (Effexor) 150 mg 1 X 1 pc
- Trazodone50mg1X1hs
- Amlodipine 10 mg 1 X 1 pc
- Simvastatin 20 mg 1 X 1 hs
Vital sign : High blood pressure
Physical examination: psychiatric examination
Speech: normal rhythm-rate-volume
Mood:
depressed mood
Affect: blunted affect
Though: coherent,
relevant, no delusion
orientation: oriented to time place person
Perception:
no hallucination
Insight: intellectual
Judgement: fair
Attention: distractibility
Labs : Scr = 0.9 mg/dL, Clcr

Assessment
45



Bipolar I disorder :
depressive episode
major depressive
disorder bipolar I disorder : manic episode 2547
CANMAT Guideline 2013
acute bipolar depression

(ECT)

mood episode
(mania/depressive)
rapid cycling mania
TCAs Atypical Antidepressant SNRIs
Bupropion TCAs SNRIs
Venlafaxine (SNRIs)
hypertension SNRIs
Lamotrigine monotherapy

Sertaline (SSRIs)

Plan
Therapeutic plan
- Lamotrigine(25) 1x1 pc for 2 wk then 50 mg/d for 2 wk,
100 mg/d for 1 wk
Maintainance 200 mg/d
- Sertaline(50) 1x1 pc
- Diazepam 5 mg 1 tab hs + prn for insomnia
Therapeutic goal
- mood episode remission
-
-
Efficacy monitoring
- mood episode
-
ADR monitoring
Lamotrigine : somnolence, dizziness, sedation, diploria, rash
Sertaline : Nausea, diarrhea, headache, insomnia, dry mouth
Diazepam : Euphoria, somnolence, rash, diarrhea
Future plan
- maintainance phase
Lamotrigine 200 mg/d
Patient education
-
-

-
-