SOAP Note # Module #

Patient Demographic Information: Pseudonym: John Riley | Age: 45 | Race: Caucasian | Marital Status: Not specified | Employment Status: Mechanic, self-identified as “Manic Mechanic” | Date of Visit: [Date of Visit]

Subjective:

Chief Complaint: “I’ve come to see you because my GP sent me here. I’ve got to tell you about my cure for cancer—it’s really important.”

HPI: John is a 45-year-old Caucasian male who was referred by his GP to the psychiatric clinic. During the session, John was preoccupied with his belief that he has developed a cure for cancer, which involves decoding messages from various clues and numbers found in newspapers and other sources. He reports receiving direct instructions from God, who tells him he is doing an exceptional job. John has been working tirelessly on this for at least a week, without sleeping, and feels he has a tremendous amount of energy. He denies any previous similar episodes, stating that this current pattern of behavior has persisted for a long time. He is highly agitated when his focus is shifted away from his theory and grows increasingly frustrated with the psychiatrist for “not paying attention.” Despite the psychiatrist’s attempt to inquire about his well-being, John insists he is “fine” and demands to speak to someone “more important.”

Past Psychiatric History: 

• No known previous psychiatric evaluations or treatments.
• No known history of inpatient or outpatient psychiatric care.
• Denies any depressive episodes or previous mental health issues.
• No known history of suicidal ideation (SI) or homicidal ideation (HI).
• No family history of psychiatric disorders per the patient, stating that his family is “not clever.”

Review of Systems:

• General: No significant physical complaints other than feeling “fantastic” and full of energy.
• Neurological: No history of headaches or neurological symptoms.
• Psychiatric: The patient presents with a grandiose delusion involving a self-proclaimed cure for cancer. He reports hearing voices, specifically from God, who gives him instructions and praises his efforts. He exhibits pressured speech, flight of ideas, distractibility, and an inability to focus on other topics. No reported suicidal or homicidal ideation.
• Cardiovascular: No reported chest pain or palpitations.
• Respiratory: No reported shortness of breath.
• Gastrointestinal: Refutes any nausea, vomiting, or changes in bowel habits.

Current Medication List (including drug allergies or write NKDA)

• John denies taking any prescription medications and states he does not need anything beyond the energy given to him by God.
• No known drug allergies (NKDA).

Objective Information:

Vital Signs: Height: 6’0” | Weight: 180 lbs | Pulse: 90 bpm | Respirations: 20 per minute | Blood Pressure: 130/85 mmHg | Temperature: 98.5°F

Physical Examination:

• General: The patient appears well-groomed, though restless and agitated.
• Neurological: No abnormalities observed. Reflexes intact.
• Cardiovascular: Heart sounds normal, regular rate and rhythm.

MSE:

• Appearance: The patient is appropriately dressed but exhibits significant restlessness.
• Behavior: Impulsive, talks over the interviewer, and is easily distracted.
• Speech: Pressured speech, rapid pace, frequent tangents.
• Mood: Elevated, euphoric, describes himself as feeling “fantastic.”
• Affect: Full range, congruent with elevated mood.
• Thought Process: Tangential and circumstantial; flight of ideas.
• Thought Content: Grandiose delusions about finding a cure for cancer and receiving direct communication from God.
• Perceptual Disturbances: Auditory hallucinations (hearing God’s voice).
• Cognition: Oriented to person, place, and time. Impaired judgment and insight.
• Insight: Poor; the patient does not recognize his need for psychiatric intervention.
• Judgment: Impaired; engages in illogical and grandiose thinking.

Any screening tools, lab, imaging, etc. (not done)

Assessment

Diagnoses:

• Bipolar I Disorder, Current Episode Manic with Psychotic Features (ICD-10: F31.2)

Rationale: Manic episodes, which can have psychotic symptoms, are a common aspect of bipolar I disorder and are frequently severe enough to significantly impede functioning (Jain & Mitra, 2023). John presents with a textbook case of mania, showing grandiosity, reduced need for sleep, racing thoughts, and pressured speech. His belief that he has discovered a cure for cancer and is receiving direct messages from God reflects mood-congruent psychotic features, where his delusions align with his euphoric mood. According to DSM-5-TR, the presence of these symptoms for a week or longer, with a marked impact on functioning, fulfills the diagnostic criteria for a manic episode. His behavior, lack of sleep, and unyielding focus on grandiose ideas demonstrate the seriousness of his condition. The psychotic symptoms resolve when the mood stabilizes, further confirming the diagnosis. A combination of mood stabilizers like lithium and antipsychotics like olanzapine is recommended for treatment, targeting both mood dysregulation and psychosis.

• Schizoaffective Disorder, Bipolar Type (ICD-10: F25.0)

Rationale: Schizoaffective disorder involves episodes of mania or depression combined with persistent psychotic symptoms such as hallucinations or delusions that occur independently of mood episodes (Miller & Black, 2019). In John’s case, he exhibits psychotic features, such as hearing God’s voice, alongside his manic episode. However, in schizoaffective disorder, psychotic symptoms should persist even when mood symptoms subside, which is not yet confirmed in John’s situation. While his grandiosity and hallucinations are closely tied to his current elevated mood, this differential diagnosis remains important, as schizoaffective disorder tends to have a more severe course due to the ongoing psychosis outside of mood episodes. The distinction between bipolar I disorder with psychotic features and schizoaffective disorder hinges on whether the psychosis persists beyond the manic or depressive phases. Careful longitudinal observation and history are necessary to rule out schizoaffective disorder and confirm that psychosis is mood-dependent.

Differential Diagnoses:

• Substance/Medication-Induced Psychotic Disorder (ICD-10: F19.159)

Rationale: Substance/medication-induced psychotic disorder occurs when psychotic symptoms, such as delusions or hallucinations, are triggered by substance use or medication, as indicated by Fiorentini et al. (2021). John denies any substance use, but this remains a differential diagnosis, particularly since substances like stimulants can cause symptoms similar to mania, including euphoria, hyperactivity, and grandiosity. Stimulant-induced psychosis could explain John’s erratic behavior, delusions about curing cancer, and hallucinations of God speaking to him. While John reports no history of substance use, patients may underreport drug use, making it critical to perform a toxicology screen to confirm this diagnosis. Additionally, certain medications or toxins could induce similar symptoms. The differential remains relevant until the possibility of substance use or medication effects can be definitively ruled out through lab testing. If toxicology results are negative and no history of medication use could explain these symptoms, this diagnosis will become less likely.

• Delusional Disorder, Grandiose Type (ICD-10: F22)

Rationale: Delusional disorder is manifested by the presence of non-bizarre, fixed delusions that last for at least one month, without prominent mood disturbance or other psychotic features like hallucinations or disorganized behavior (Joseph & Siddiqui, 2023). In the grandiose subtype, individuals believe they possess exceptional abilities or talents, similar to John’s belief that he has found a cure for cancer and is in direct communication with God. While this could indicate grandiose delusional disorder, John’s other symptoms—such as his expansive mood, flight of ideas, and decreased need for sleep—point more strongly to a mood disorder, specifically bipolar I disorder with psychotic features. In delusional disorder, mood disturbances do not dominate the clinical picture as they do in John’s case, and there is an absence of additional psychotic symptoms such as hallucinations. Nevertheless, this differential diagnosis should remain in consideration until more clarity is gained regarding the prominence and persistence of his delusions outside of manic episodes.

Plan

Pharmacological Treatment

• Lithium 300 mg PO TID, titrate upwards to attain serum levels of 0.6-1.2 mEq/L.

Rationale: Lithium is a first-line mood stabilizer for bipolar I disorder with proven efficacy in treating manic episodes, as noted by Chokhawala et al. (2024).

• Olanzapine 10 mg PO daily.

Rationale: An atypical antipsychotic is indicated to address John’s psychotic features, such as delusions and auditory hallucinations (Thomas & Saadabadi, 2023).

Non-Pharmacological Treatment: 

• Immediate psychiatric follow-up with a focus on psychoeducation regarding bipolar disorder and adherence to treatment.
• Cognitive behavioral therapy (CBT) to address distorted thinking patterns and improve insight (Nakao et al., 2021).
• Family therapy to provide support and education for John’s family on managing his condition.

Education (to patient and family as applicable): 

Bipolar disorder is a chronic mood disorder that involves episodes of mania, hypomania, and depression. Proper management includes pharmacological treatments, psychotherapy, and lifestyle adjustments. It is crucial for patients to understand the importance of adhering to prescribed medications, even when they feel well, as irregular medication use can trigger relapse. Medications like mood stabilizers (like lithium) and antipsychotics (such as olanzapine) are commonly used to control manic and depressive episodes, but they require regular monitoring due to potential side effects, including kidney and thyroid issues in the case of lithium (Geddes & Miklowitz, 2013).

Notably, non-pharmacological approaches such as CBT can improve outcomes by helping patients manage symptoms, cope with stress, and recognize early warning signs of mood episodes (Chand et al., 2023). Psychoeducation for both the patient and their family is essential to foster understanding of the disorder, improve medication adherence, and reduce stigma. Family involvement can enhance support networks and contribute to better long-term outcomes.

Additionally, lifestyle modifications are critical in managing bipolar disorder. Regular sleep patterns, reduced alcohol or stimulant intake, and structured daily routines can help stabilize mood fluctuations (Murray et al., 2020). Patients are encouraged to engage in consistent, moderate physical activity, maintain social interactions, and avoid substance use to prevent exacerbations of symptoms.

References

Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2023, May 23). Cognitive behavior therapy (CBT). National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470241/

Chokhawala, K., Saadabadi, A., & Lee, S. (2024). Lithium. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519062/

Fiorentini, A., Cantù, F., Crisanti, C., Cereda, G., Oldani, L., & Brambilla, P. (2021). Substance-induced psychoses: An updated literature review. Frontiers in Psychiatry, 12(12). https://doi.org/10.3389/fpsyt.2021.694863

Jain, A., & Mitra, P. (2023, February 20). Bipolar disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558998/

Joseph, S. M., & Siddiqui, W. (2023, March 27). Delusional disorder. PubMed. https://pubmed.ncbi.nlm.nih.gov/30969677/

Miller, J. N., & Black, D. W. (2019). Schizoaffective disorder: A review. Annals of Clinical Psychiatry: Official Journal of the American Academy of Clinical Psychiatrists, 31(1), 47–53. https://pubmed.ncbi.nlm.nih.gov/30699217/

Murray, G., Gottlieb, J., & Swartz, H. A. (2020). Maintaining daily routines to stabilize mood: Theory, data, and potential intervention for circadian consequences of COVID-19. The Canadian Journal of Psychiatry, 66(1), 9–13. https://doi.org/10.1177/0706743720957825

Nakao, M., Shirotsuki, K., & Sugaya, N. (2021). Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. BioPsychoSocial Medicine, 15(1), 1–4. https://doi.org/10.1186/s13030-021-00219-w

Thomas, K., & Saadabadi, A. (2023, August 28). Olanzapine. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532903/

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 SOAP note—bipolar disorder -adult, pediatric, or geriatric

After watching the video, please complete a Case Analysis Evaluation using the provided SOAP Note Template .

Video link:  https://www.youtube.com/watch?v=zA-fqvC02oM&list=PLnyL-0BNCHtLZhjQOz5z5fW6cNPm8Vbr1&index=3

In the treatment section list the medication(s) you would prescribe at this visit.  Make sure you provide a rationale for your decision.

Criteria

Demographic Information

Chief Complaint

History of Present Illness

Past Psychiatric History

Review of Systems

Description of criterion

Medication List

Vital Signs

Physical Exam

Mental Status Exam

Diagnoses With Rational (include ICD 10 CODE AND SPECIFIERS)

Differential Diagnoses (include ICD 10 CODE AND SPECIFIERS)

Pharmacological treatment

Non-Pharmacological Treatment

Education

References