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Hello, this assignment is a SOAP Note, I have attached one SOAP note with the format you have to do. Lets do it about a male patient with depression. Please add 3 differential diagnosis. The medication for this patient is Escitalopram 10 mg PO daily. The patients is not aggressive and does not want to kill himself. Thank you!
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Soap Note 1: Bipolar Disorder II
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PATIENT INFORMATION:
NAME: Mrs. C.Y.
AGE: 32
SEX: Female
SOURCE: Patient
ALLERGIES: NKDA
CURRENT MEDICATIONS: None
PMHX: None.
FAMHX: The patient’s maternal grandfather was diagnosed and treated for Anxiety.
There have been no reports of any other family member with a history of mental illness.
SOCHX: The patient lives with her parents, and she is not currently working. She has
strained relationships we family members because of her unpredictable mood swings. She
withdrew from the Nursing School because of failing the tests and challenges focusing on
her studies.
SUBJECTIVE:
CC: “My daughter has been more talkative than usual in the last few days and is
becoming more irritable.”
HPI: The 32 year-old female patient, accompanied by her mother, has reported an erratic
mood and irritable symptoms to the facility. Mother is providing information on patients
behalf. According to the mother, for the past 2 months, the patient has had racing
thoughts, difficulty falling or staying asleep, and at least four days of episodes. She has
never experienced this episode, does not sleep, and is hyper-focused. The mother says
that in the past three days, the patient has been more talkative than usual and is easily
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irritable and distracted. She denies headaches, chills, or fever. However, the mother
reports that the patient has lost at least 20 kg in the last year.
ROS:
Constitutional: Reports will have lost at least 20 kg in the last 12 months. Denies fevers
or chills.
Neurologic: Denies changes in LOC, tremors, or seizures.
HEENT: HEAD: Denies any deformity, wounds, or injuries. EYES: Denies discharge or
disturbances individual capacity. EARS: Denies hearing loss, pain, or discharge. NOSE:
Denies condition, drainage, or bleeding. THROAT: Denies hoarseness of voice, pain, or
difficulty swallowing.
Respiratory: Denies wheezing, shortness of breath, and or persistent coughs.
Cardiovascular: Denies chest pain, chest tightness, or palpitations.
Gastrointestinal: Denies abdominal pain, constipation, disruption of bowel movement,
nausea, and vomiting.
Musculoskeletal: Denies compromised range of motion.
OBJECTIVE:
Constitutional: Blood pressure 120/80, heart rate 92, respirations 20, temperature 98.2,
height 5’5”, weight 120lbs, BMI 20.
Neurologic: Intact sensation bilaterally; Bilateral UE/LE strength 4/5.
HEENT: No major concern is evident in HPI and ROS.
Cardiovascular: RRR without rubs, murmurs, or gallops. S1/S2 present.
Respiratory: Lungs are well functioning and clear to auscultation. Negative for difficulty
breathing, persistent cough, or wheezing.
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Gastrointestinal: No major concern is evident in HPI and ROS.
Musculoskeletal: No major concern, as evident in HPI and ROS.
Integumentary: Negative for lesions, wounds, or dry skin.
Mental Status Exam
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Attitude: Agitated when asked questions, evasive and loud.
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Appearance: Moderately well-nourished and disheveled.
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Psychomotor: Erratic and restless.
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Affect: Hostile, hyperactive, and labile.
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Mood: Suspicious, angry, and agitated.
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Speech: Depends on circumstance. Sometimes it is intelligible and, in other cases,
tangential.
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Though content: Delusional, psychotic, paranoid, and disorganized.
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Cognitive assessment: Not oriented to place and person. Need help answering
questions effectively. Impairment in the recent, intermediate, and remote memory.
She appears to be unaware of what she is doing.
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Judgments and insights: Refuses to respond to questions about the ability to
control thought processes.
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Assets: Does better when calm.
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Limitations: Behaves unsafely and can cause self-harm.
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Formulation: Bipolar II disorder with depression.
ASSESSMENT:
Bipolar II disorder (F31. 81): A type of bipolar disorder in which an individual presents
with hypomanic episodes and depression. In most cases, an individual will present with at
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least one depressive episode every two weeks and a hypomanic episode lasting up to four
days. In the patient’s case, he presents with hypomanic symptoms, which include
constantly elevated and irritable mood (Lee et al., 2020). This explains the reason for the
positive diagnosis of bipolar II disorder.
Bipolar I disorder (F31): A condition correct rise by at least one manic episode in the
last time of an individual. For people with bipolar I disorder, they present with more
severe symptoms that are disruptive to their routine lives. In most cases, when they
experience a maniac absurd, it can last for up to seven days. The severity of these maniac
episodes explains why it is important that your subject is to immediate medical attention
(McIntyre et al., 2020).
Disruptive mood dysregulation disorder (DMDD) (F34. 8) is a mental health condition
associated with a chronically irritable mood that gradually becomes severe. This
condition is usually diagnosed among individuals aged 6-18 years. An individual with the
condition does not exhibit sleeplessness, goal-directed behavior, or euphoria, which is
often associated with maniac results among individuals with bipolar disorder. The
chronic and severe nature of the irritable mood explains why DMDD was ruled out
(Benarous et al., 2020).
PLAN:
Pharmacological Interventions
Lithium 300mg TID help with managing irritable mood and maniac symptoms.
Pharmacologic Treatment
Incorporate cognitive behavioral therapy so that the patients navigate any
depressive symptoms and irritable mood that affects the capacity to engage in activities
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of daily living. It will also provide an opportunity to ensure that the patient can identify
and address the attributes that are necessary or ineffective when dealing with the health
condition (Benarous et al., 2020).
Family and patient education is very important, and it will require the active
engagement of family members to help with navigating the challenges that the patient
experiences. The education process will prioritize the need to adhere to the prescribed
medication. Education will focus on the rationale of the medication in helping to treat and
manage bipolar II disorder, the side effects of the medication, and the symptoms that the
patient must observe to seek medical attention. The patients can also benefit from
referrals to a cultural support group (Benarous et al., 2020). This will be instrumental in
ensuring an awareness of the best and culturally sensitive approaches that can be
effective when managing irritable mood and other symptoms associated with bipolar II
disorder.
Follow-ups/Referrals: The patient’s bipolar II disorder can be managed within the
facility, and there is no need for any referrals. However, the patient and her mother
booked a follow-up appointment in two weeks, which will provide a platform and an
opportunity to determine the best and most effective ways of understanding the disease
progression and the extent to which the interventions appropriately address the existing
concerns.
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References
Benarous, X., Bury, V., Lahaye, H., Desrosiers, L., Cohen, D., & Guilé, J. M. (2020).
Sensory processing difficulties in youths with disruptive mood dysregulation
disorder. Frontiers in psychiatry, 11, 164.
Lee, S. Y., Lu, R. B., Wang, L. J., Chang, C. H., Lu, T., Wang, T. Y., & Tsai, K. W.
(2020). Serum miRNA as a possible biomarker in the diagnosis of bipolar II
disorder. Scientific reports, 10(1), 1131.
McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L.
V., … & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 18411856.
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