Comprehensive Focused SOAP Psychiatric Evaluation Topic: Bipolar Disorder
S – Subjective
Chief Complaint (CC): “I feel like I’m either on top of the world or completely unable to get out of bed.”
History of Present Illness (HPI): Patient reports alternating episodes of elevated mood, increased energy, decreased need for sleep, and impulsive spending lasting about 1–2 weeks, followed by periods of profound sadness, hopelessness, and fatigue. Symptoms have been present for several years, worsening in the past 12 months. Denies current suicidal ideation but admits to past fleeting thoughts during depressive episodes.
Psychiatric History: Prior diagnosis of depression at age 20; treated with SSRIs with limited benefit. No prior hospitalizations. Family history significant for mood disorders (mother with depression, uncle with bipolar disorder).
Substance Use: Occasional alcohol use; denies illicit drugs. Caffeine intake high (4–5 cups/day).
Social History: College graduate, currently employed. Reports strained relationships due to unpredictable mood swings. Lives alone, limited support system.
Review of Systems (ROS):
Mood: Fluctuates between euphoric and depressed.
Sleep: Decreased need for sleep during mania; hypersomnia during depression.
Energy: Excessive during mania, low during depression.
Appetite: Increased during depression, decreased during mania.
Concentration: Poor during both phases.
Safety: Denies current suicidal or homicidal ideation.
O – Objective
General Appearance: Well-groomed, casually dressed. During interview, speech pressured and rapid, mood elevated, affect labile.
Mental Status Examination (MSE):
Orientation: Alert and oriented ×3.
Speech: Pressured, tangential at times.
Mood: “Excited, unstoppable.”
Affect: Expansive, congruent with mood.
Thought Process: Flight of ideas, occasional distractibility.
Thought Content: No delusions or hallucinations noted.
Cognition: Impaired concentration, intact memory.
Insight/Judgment: Limited insight into illness; judgment impaired during manic episodes.
Vital Signs: Within normal limits.
Physical Exam: No acute abnormalities.
Labs/Screening: Thyroid function normal; urine drug screen negative.
A – Assessment
Primary Diagnosis: Bipolar I Disorder – characterized by at least one manic episode lasting ≥7 days or requiring hospitalization, often alternating with depressive episodes.
Differential Diagnoses:
Major Depressive Disorder (MDD) – ruled out due to presence of mania.
Cyclothymic Disorder – less severe, shorter duration mood swings.
Substance-Induced Mood Disorder – ruled out by negative drug screen.
ADHD – overlapping symptoms (impulsivity, distractibility) but lacks mood cycling.
Risk Assessment:
Suicide risk: Moderate during depressive episodes.
Safety risk: Impulsive behaviors during mania (spending, risky sexual activity).
Protective factors: Employment, willingness to seek treatment.
P – Plan
Pharmacological Interventions:
Initiate mood stabilizer (e.g., lithium, valproate, or lamotrigine).
Consider atypical antipsychotic (e.g., quetiapine, olanzapine) for acute mania.
Avoid antidepressant monotherapy due to risk of triggering mania.
Psychotherapy:
Cognitive Behavioral Therapy (CBT) for depressive symptoms.
Psychoeducation about illness course, triggers, and medication adherence.
Family-focused therapy to improve support system.
Lifestyle/Supportive Measures:
Sleep hygiene and structured daily routine.
Limit caffeine and alcohol.
Encourage exercise and balanced diet.
Crisis plan for suicidal ideation (emergency contacts, hotline).
Follow-Up:
Weekly visits initially to monitor medication response and side effects.
Regular lab monitoring (lithium levels, renal and thyroid function).
Long-term goal: Stabilize mood, reduce relapse frequency, improve functioning.
✅ Summary
This SOAP evaluation demonstrates how to apply the NRNP/PRAC 6665 & 6675 template to a psychiatric case of Bipolar Disorder. It integrates subjective patient reports, objective findings from the mental status exam, diagnostic reasoning, and a comprehensive treatment plan.
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