SOAP Notes Week 5

Yekaterina Ambrose
Herzing University
Psychiatric Mental Healthcare, NU673-7
Dr. Keith Jenkins
June 11, 2023
 Clinical Note
Informed consent was given to patient about psychiatric interview process and
psychiatric/psychotherapy treatment.
Pt’s name: C.K.
DOB: 10/08/1998
Accompanied by: Mother
Demographic: White, Caucasian
Gender Identifier Note: Female
Subjectives:
Chief Complaint: Pt’s mother reports: “My daughter's Bipolar disease has gotten
worse, and she has stopped taking her medication”.
HPI: Pt was brought into the Clinic by her mother. Pt’s mother reports that patient
has been diagnosed with Bipolar, type 1 disorder 5 month ago and was started on
Lithium and Zyprexa which were working until recently. Pt’s mother states that a
week ago her daughter stopped taking her medications, because “she did not think
she needed them anymore”. A week ago, the patient started to experience severe
mood abnormalities such as irritability, grandiosity and “excessive talking. Pt’s
mother reports that her daughter, who was currently in long term relationships with
her boyfriend, has been calling out to her other male friends from her past
relationships and inviting them for a date. When mother asked her why she
behaves this way, daughter stated that” she really feels like she wants to have
variety in her sexual life at this time”. Pt’s mother also reports that patient has been
sleeping about 4 hours per day for the last week, and has been exercising
excessively in the basement, "trying to lose weight”. Pt’s mother is extremely
concerned about patient’s current state and was wondering if her daughter has to be
admitted impatiently, however wanted to get an opinion from outpatient provider
first.
During the interview, the patient was sitting in the chair, using her cell phone.
Patient was noted talking to herself and laughing inappropriately at times. Patient
was wearing lurid clothes and wearing bright make-up. When the patient was
asked why she is here, the patient replied: “Do not ask me. My mom is the one
who brough me here. She always worries about me, but I am feeling great, perhaps
it is the best I felt in years, life is amazing right now. "When patient was asked
about her bipolar disorder, she stated:” I remember I was diagnosed with it, but It
is gone now, I am cured". Patient denied SI, HI, AVH.
Past Medical History:
Medical history: pt denies cardiac, respiratory, endocrine and neurological issues,
denies history of chronic infections, including MRSA, TB, HIV, Hep C.
Surgical history: appendectomy (2010)
Past Psychiatric History:
The patient was diagnosed with Bipolar, type 1 disorder on 01/ 21/2023 after
experiencing manic episode. Patient was admitted inpatient for comprehensive
evaluation and treatment of acute manic episode. The patient was started on
Lithium 300mg BID, and Zyprexa (Olanzapine) 5 mg HS, and Klonopin
(Clonazepam), 1 mg Q 6 hours, PRN, which were effective.
Safety Concerns:
History of violence to self: none reported.
History of violence to others: none reported.
Auditory hallucinations: none reported.
Visual hallucinations: none reported.
Mental health treatment history:
History of outpatient treatment: this writer has been seeing this patient since
02/03/2023.
Previous psychiatric hospitalizations: Pt was admitted to voluntary psychiatric unit
at UMSJMC from 01/19/2023 to 01/30/2023.
Prior substance abuse treatment: none reported.
Trauma history:
Patient does not report history of trauma including abuse, domestic violence,
witnessing disturbing events.
Substance use:
Patient denies use or dependence of ETOH, tobacco products or illicit drugs.
Current medications:
-Lithium Carbonate (Eskalith) PO, started on 01/21/23. Initial dose was 300 mg
BID and was titrated up to 450 BID. The last Lithium plasma level was 04/13/2023
and it was 0.9 mEq/L.
-Zyprexa (Olanzapine), PO, started on 01/21/23. Initial dose was 5 mg HS, and it
was increased to 10 mg HS.
-Klonopin (Clonazepam),PO, 1 mg Q 6 hours PRN (for anxiety/agitation).
-New Day (Levonorgestrel), PO, 15 mg, QD.
Supplements:
Women’s Multivitamins, PO, 1 capsule, QD.
Allergies: NKDFA
Family Psychiatric history:
Substance abuse: maternal Uncle suffers from Cocaine abuse
Suicides: none reported.
Psychiatric diagnoses: maternal uncle does have signs/symptoms of bipolar
disorder, but was never officially diagnosed with it, due to refusal of
evaluation/treatment.
Social History:
Patient resides with her parents and is currently unemployed. Patient has been
dating her boyfriend for 4 years, but” their relations have gotten worse since
patient has been diagnosed with Bipolar and admitted to psychiatric facility in
January 2023”.
Military services history: none reported.
Education history: Patient has a high school diploma. Pt has started IT program at
Loyola University but was not able to finish it after failing her first semester in
college.
Developmental history: no significant detail reported.
Legal history: no reported/known legal issues.
Spiritual/ Cultural considerations: patient and her family do not follow any specific
religion.
ROS:
Constitutional: no report of fever or weight loss.
Cardiac: no report of chest pain, edema or palpitations.
Respiratory: no report of dyspnea, cough or wheezing.
Endocrine: patient reports Polyuria and Polydipsia that started a week ago.
Psychiatric: patient denies suicidal/homicidal ideations, denies AVH, denies
violent behaviors, denies inappropriate behaviors. Pt states: “I am here just because
my mom really wanted me to come. I do not have any complaints and I am feeling
better than I ever felt, my life is amazing”.
Objectives:
VS: T 99.1, BP 146/83, HR 92, RR 20, O2 99%.
Pain: none reported.
Ht: 5.4
Wt: 124 ibs ( last Wt check was on 02/03/2023 and it was 131 ibs)
BWI: 21.3 (normal)
LABS: (as of 01/21/2023)
-WBC:WNL
-TSH: 2.8, T4: 54
-BPM: WNL
-Creatinine: 1.2
-HCG: negative
-EKG: unremarkable
-Lithium plasma level: 0.9 mEq/l (as of o4/13/2023)
Physical exam:
MME:
Appearance: 25 years old white Caucasian female, appears stated age. Pt was
sitting in the chair, with her legs crossed in somewhat seductive position. Pt was
using her cell phone through the entire interview with pt’s mother. Pt was noted
talking to herself and laughing at times, pt appears to be hyperactive and restless.
Pt was wearing lucid, not weather appropriate clothes and wearing a bright make-
up.
Speech: loud, rapid, pressured, difficult to interrupt.
Mood: patient rates her mood is:” the best mood I ever had”.
Affect: expensive, euphoric.
Thinking and perception: flight of ideas, rapid thinking, tangential. Pt appears to
have no insight into her illness.
Perceptual disturbances: patient denied any AVH; however, pt was noted talking
and laughing to herself; pt appears to be responding to internal stimuli.
Cognition: pt is oriented to person, place and time, however pt is not aware of
reason for this visit and stated that she is here is only because her mom asked her
to come to this appointment. Pt’s remote and recent memory appear to be impaired.
Pt’s concentration appears to be impaired (pt was not able to subtract 7 from 100
and keep subtracting 7). Pt’s fund of knowledge appears to be fair, pt’s insight
appears to be lacking (complete denial of illness.)
Patient is not able to articulate needs, is not motivated for compliance and
adherence to medication regiment at this time. Pt is not willing to participate with
treatment, disposition, and discharge planning.
Assessment:
Dx- bipolar disorder, type 1, current manic episode, moderate. ( ICD 10 code-
F31.12)
Differential diagnoses:
-Mood disorder due to general medical condition. (F06.31)
-Substance-induced mood disorder. (F19.14)
-Bipolar mixed episode. (F31.6).
Patient does not have ability/capacity to respond to psychiatric
medication/psychotherapy at this time. Pt does not appear to understand the need
for medication/psychotherapy and is not willing to maintain adherent.
Reviewed potential risks and benefits, Black Box warnings and alternatives
including declining treatment.
Plan:
It is appearing that patient is experiencing a Manic episode of bipolar disorder.
According to pt’s mother, who brought the patient in today, patient stopped taking
her medication a week ago. Pt’s mother reports that patient has been “exercising
excessively "for over a week, which is concerning, considering patient has been
taking Lithium since January. The patient’s last Lithium level was on 04/ 13/2023.
Patient requires immediate workup done to be done, however due to pt’s denial of
her illness and current manic episode, patient will have to be admitted impatiently
as of today for comprehensive assessment and medication management.
Safety risks/plan: patient is found to be unstable and does not have control of their
behavior. Patients likely pose a moderate risk to themselves and others at this time.
Patient appears to be responding to internal stimuli.
Pharmacological interventions:
- patient’s medication will likely need to be modified by adding another
anticonvulsant to the medication regiment (Divalproex (Depakote), and/or
Carbamazepine (Tegretol)).
-ECT consultation might be beneficial for this patient.
Education/promotion:
Patient’s mother was educated on Lithium (Eskalith) side effects, signs of toxicity,
and importance of hydration. Pt’s mother was educated on importance of regular
blood test while taking this medication, as well as about importance to prevent
pregnancy while taking Lithium.
Patient’s mother was educated on Olanzapine (Zyprexa) side effects such as:
dizziness, sedation, dry mouth, constipation, weight gain, tachycardia, orthostatic
hypotension and risk for diabetes melius. Pt’s mother was also educated about
importance of absence of any tobacco products while taking Olanzapine.
Pt’s mother was educated on Klonopin (Clonazepam) side effects such as:
sedation, fatigue, dizziness, ataxia, slurred speech and confusion. Pt’s mother was
also educated about high risk of addiction while taking any kind of
Benzodiazepines.
-Safety plan was completed.
-Follow-up: preferable next day following discharge from Inpatient facility.
Visit lasted: 50 minutes
Billing code for visit:
99215
Yekaterina Ambrose, PMHNP
6/10/2023 11:52 am.