Unit 8 Anxiety Case Study

Read the case study as listed and complete a SOAP note for an intake. Use the attached rubric.
· What additional information do you need for subjective and objective data?

Next, design a treatment plan based on the information you have available; include pharmacological, non-pharmacological, patient education, referral, and follow-up.

Milton is a 68-year-old Asian American male who reports that his biggest problem is worrying non-stop. He worries all of the time and about “everything under the sun and beyond.” For example, he reports equal worry about his wife who is undergoing treatment for breast cancer, and whether he returned his book to the library yesterday to maintain a good patron status. He recognizes that his wife is more important than a book and is bothered that both cause him similar levels of worry even when he tries to rationalize the differences. Milton is unable to control his worrying with current mechanisms that he lists as distraction or self-talk. Supplementary, this excessive and uncontrollable worry is creating difficulty falling asleep and staying asleep, constant impatience with others, difficulty focusing at work, and significant back and muscle tension. Milton has had a lifelong problem with worry, recalling that his mother called him a “worry wart as a child.” His worrying does “wax and wane”, and worsened when his wife was recently diagnosed with breast cancer. He feels he is at a loss for what he can do to control it and relax.

Symptoms:

· Anxiety

· Concentration Difficulties

· Irritability

· Sleep Difficulties

· Worry

Vitals:

132/80 BP

72 HR

20 R

98.8 T

98% 02

Ht. 5’5”

Weight 149

Complete this assignment and submit it to this assignment dropbox by Sunday at 11:59 pm CT.

Estimated time to complete: 3 hours

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Sample

Unit 5 SOAP Notes bipolar

SOAP Note

Subjective:

Chief complaint (in patient’s own words): “I’ve been feeling really up and down lately. One minute I’m on top of the world and can’t stop moving and talking, and the next I’m crashing hard and just want to stay in bed all day.”

History of present illness: The patient is a 28-year-old female who presents with worsening symptoms of bipolar disorder over the past 2-3 weeks. She reports experiencing periods of elevated mood, increased energy, racing thoughts, pressured speech, and a decreased need for sleep alternating with periods of depressed mood, fatigue, lack of motivation, and social withdrawal. During the manic phases, she describes feeling “like I’m on fire and can conquer the world.” She has exhibited impulsive behaviors such as excessive spending and hyper-sexuality. She states, “I went on a huge shopping spree and maxed out three credit cards buying unnecessary things.” She has also experienced periods of irritability and has had conflicts with family members during these episodes. The depressive episodes are characterized by persistent low mood, anhedonia, poor concentration, feelings of worthlessness, and thoughts of “not wanting to go on.” She reports difficulties getting out of bed and a lack of self-care during these times

Current Medications: Lithium 600 mg daily, Aripiprazole 10 mg daily

Allergies: No known drug allergies

Past Medical History: Unremarkable

Past Psychiatric History: Diagnosed with Bipolar I Disorder at age 22 after first manic episode with psychotic features requiring hospitalization. Multiple subsequent episodes over the years.

Family History: Mother has a history of major depressive disorder.

Relevant personal and social history: The patient is currently unmarried and lives alone in an apartment. She has a close relationship with her parents, who provide support, but strained relationships with some other family members due to the erratic nature of her illness. She works part-time as a graphic designer but has struggled to maintain consistent employment during acute episodes. She denies any history of substance abuse or legal issues. No recent significant psychosocial stressors were identified.

Objective:

Vitals: BP 132/88, HR 98, RR 16, Temp 98.6°F

ROS: Positive for sleep disturbance, poor concentration, pressured speech as described above. Otherwise negative.

Mental Status Exam:

· Appearance – Disheveled, overly groomed with excessive makeup

· Behavior – Hyperactive, fidgety, easily distracted

· Speech – Loud, pressured, rapid rate

· Mood – Euphoric

· Affect – Mood-congruent, labile, broad range

· Thought Process – Flight of ideas, tangential Thought Content – No overt delusions or paranoia

· Perceptions – Denies hallucinations

· Cognition – Intact attention and concentration, recent/remote memory intact

· Insight – Fair, minimizes symptoms at times

· Judgment – Fair Other – Psychomotor agitation

Psychiatric Screening Measures: PHQ-9 – 6 (Minimal depression) MDQ – Positive screen for bipolar disorder

Psychiatric Screening Measures: PHQ-9 – 6 (Minimal depression) MDQ – Positive screen for bipolar disorder (Roberts, L. W. (Ed.). (2019).

Assessment:

Diagnosis: Bipolar I Disorder, Current Episode Manic, Severe (F31.2)

DSM-5 Criteria Met:

· Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy

· Mood disturbance sufficient to cause marked impairment in social/occupational functioning

· At least 3 of the following (4 if mood is only irritable): grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, excessive involvement in pleasurable activities with potential for painful consequences

· Not attributable to physiological effects of a substance or other medical condition (American Psychiatric Association. (2013).

Potential Obstacles to Treatment:

· Medication non-adherence

· Lack of consistent social support system

· Vocational and financial instability

· Potential for insight to worsen during acute manic episodes

· Stigma associated with mental illness

Plan:

• Adjust medication regimen:

• Increase lithium dose to 900 mg daily (obtain lithium level after 5 days)

• Increase aripiprazole to 20 mg daily

• Add lorazepam 1-2 mg every 6 hours as needed for agitation/insomnia (Roberts, L. W. (Ed.). (2019).

• Refer to partial hospitalization program for intensive therapy, psychoeducation on bipolar disorder, and medication management. Coordinate family involvement.

• Psychotherapy:

• Individual therapy focused on cognitive behavioral strategies, coping skills, trigger identification

• Family therapy to increase support system’s understanding of the illness

• Encourage maintaining regular sleep/wake cycle, limiting potential triggers (caffeine, stress), and engaging in relaxation techniques like mindfulness.

• Consider involvement of case manager or community resources to assist with adherence and functional support during acute episodes. (McIntyre et al., 2020)

• Follow up appointment in 2 weeks:

• Assess response to medication changes and need for further adjustments

• Evaluate for presence of depressive or psychotic symptoms

• Review any labs (lithium level, metabolic monitoring)

• Coordinate step-down level of care if stabilized (Roberts, L. W. (Ed.). (2019).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

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), 1841-1856. https://doi.org/10.1016/S0140-6736(20)31544-0

Roberts, L. W. (Ed.). (2019). The American Psychiatric Association publishing textbook of psychiatry. American Psychiatric Pub.

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