SOAP Note: Schizoaffective Disorder, Bipolar Type

S: Subjective

• Chief Complaint: “I’ve been hearing voices and feeling paranoid.”
• History of Present Illness:

The patient, John Doe, 29, visits the outpatient clinic with complaints of auditory hallucinations and paranoid delusions. He reports hearing voices that condemn what he does and warns him of impending dangers, which he feels are imminent. He has approximately four weeks of these symptoms, and he denies having had any similar problems before: SOAP Note: Schizoaffective Disorder, Bipolar Type.

He also complains about unstable moods, sometimes feeling irritable or having too much energy, but never having high moods and activity like in mania. He says he is confused about what is real and has problems distinguishing between his thoughts and reality. His functionality in social and professional life has been significantly affected by the persistence of the symptoms.

• Past Medical History:
  • No significant medical history.
  • No history of chronic illnesses or previous hospitalizations.
• Medications: No current medication use.
• Allergies: No known drug and food allergies.
• Social History: The patient lives alone and has limited social support. He reports a history of alcohol use, drinking approximately one bottle two to three times a week, but denies substance abuse. He has not been employed for six months and has been socially withdrawn.
• Family History: He is the second born in a family of four. The mother has a history of depression, and the father has a history of hypertension. There is no known history of psychotic disorders or mood disorders in the family.

Review of Systems:

• Constitutional:
  • ☐ Fever ☐ Weight loss ☐ Fatigue ☐ Weakness ☒ Other: No significant symptoms reported.
• Head, Eyes, Ears, Nose, Throat (HEENT):
  • ☐ Headache ☐ Vision changes ☐ Hearing loss ☐ Nasal congestion ☐ Sore throat ☒ Other: No issues reported with HEENT.
• Cardiovascular:
  • ☐ Chest pain ☐ Palpitations ☐ Shortness of breath ☐ Edema ☒ Other: No cardiovascular complaints.
• Respiratory:
  • ☐ Cough ☐ Wheezing ☐ Hemoptysis ☐ Shortness of breath ☒ Other: No respiratory issues.
• Gastrointestinal:
  • ☐ Nausea ☐ Vomiting ☐ Diarrhea ☐ Constipation ☐ Abdominal pain ☒ Other: No gastrointestinal symptoms.
• Genitourinary:
  • ☐ Dysuria ☐ Frequency ☐ Hematuria ☐ Urgency ☐ Incontinence ☒ Other: No genitourinary concerns.
• Musculoskeletal:
  • ☐ Joint pain ☐ Muscle pain ☐ Stiffness ☐ Swelling ☒ Other: No musculoskeletal issues reported.
• Neurological:
  • ☐ Headaches ☐ Dizziness ☐ Numbness ☐ Tremors ☐ Seizures ☒ Other: Reports psychomotor agitation, restlessness, auditory hallucinations, paranoia, and difficulty distinguishing between reality and delusion.
• Skin:
  • ☐ Rash ☐ Itching ☐ Dryness ☐ Lesions ☒ Other: No skin abnormalities.
• Endocrine:
  • ☐ Weight changes ☐ Heat intolerance ☐ Cold intolerance ☐ Excessive thirst ☒ Other: No endocrine symptoms.
• Hematologic/Lymphatic:
  • ☐ Easy bruising ☐ Bleeding ☐ Swollen glands ☒ Other: No hematologic concerns.

O: Objective

• Vital Signs:
  • Blood Pressure: 129/86 mmHg
  • Heart Rate: 88 beats per minute
  • Respiratory Rate: 16 breaths per minute
  • Temperature: 98.6 degrees Fahrenheit
• Physical Examination:

The patient is presentably disheveled and poorly groomed, which aligns with a self-care deficit. Neurologic examination shows normal motor activity. However, the patient seems to be in significant psychomotor agitation. No signs of acute distress, tremors, or restlessness are present.

The patient speaks in a pressured, incoherent manner. Normal cardiovascular, respiratory, and abdominal examination findings. The mental status exam shows that he has disorganized thoughts, pressured speech as well as poor insight regarding his condition.

Mental Status Exam:

• Appearance:
  • ☐ Well-groomed ☒ Disheveled ☒ Poor hygiene ☒ Other: Inadequate of self-care.
• Behavior:
  • ☐ Calm ☒ Agitated ☐ Cooperative ☒ Uncooperative ☒ Other: Restless
• Speech:
  • ☐ Normal rate ☒ Pressured ☐ Slow ☒ Incoherent ☐ Other: _________________
• Mood:
  • ☐ Euthymic ☒ Depressed ☒ Anxious ☐ Euphoric ☒ Other: Paranoid mood
• Affect:
  • ☐ Appropriate ☒ Flat ☐ Labile ☐ Inappropriate ☒ Congruent with stated mood ☐ Other: ___________________
• Thought Process:
  • ☐ Logical ☒ Disorganized ☒ Tangential ☐ Circumstantial ☐ Other: ___________________
• Thought Content:
  • ☐ No delusions ☒ Delusions ☐ Obsessions ☐ Preoccupations ☒ Other: Delusions of persecution and paranoia.
• Perceptions:
  • ☐ No hallucinations ☒ Hallucinations ☐ Illusions ☒ Other: Auditory hallucinations
• Cognition:
  • Orientation:
    • ☒ Oriented to person ☒ Oriented to place ☒ Oriented to time ☒ Oriented to situation
  • Attention:
    • ☒ Able to focus ☒ Easily distracted ☐ Difficulty concentrating ☐ Other: ___________________
  • Memory:
    • ☒ Intact ☐ Recent memory impaired ☐ Remote memory impaired ☐ Immediate memory impaired
  • Abstract Thinking:
    • ☒ Able to interpret proverbs ☐ Difficulty with abstract thinking ☒ Concrete thinking ☐ Other: ___________________
  • Insight:
    • ☐ Good ☐ Fair ☒ Poor ☐ No insight ☐ Other: ___________________
  • Judgment:
  • ☐ Good ☐ Fair ☒ Poor ☐ Impaired ☐ Other: ___________________

A: Assessment

• Summary of Findings:

The patient exhibits severe psychiatric symptoms, including auditory hallucinations and paranoid delusions. Mental status examination depicts disorganized thinking, pressured speech, and a lack of insight regarding his condition. The physical examination did not reveal any abnormalities on the physical side, and there is no acute medical illness that could be causing the psychiatric symptoms.

The patient’s hygiene and self-care are in an impaired state, with signs of functional impairment caused by psychotic symptoms. Clinical presentation confirms a psychotic disorder but needs further assessment to determine the best diagnosis.

• Diagnosis
  • Primary Diagnosis
    • Schizoaffective Disorder, Bipolar Type (ICD-10 Code: F25.1)

Schizoaffective disorder is characterized by the presence of manic, depressive, or mixed-mood episodes and hallucinations or delusions of psychotic symptoms. The patient meets the DSM-5 criteria for schizoaffective disorder due to the concurrent occurrence of mood episodes (possible bipolar symptoms) alongside psychotic symptoms such as auditory hallucinations and paranoia, which have persisted for over two weeks (Wy & Saadabadi, 2023). Specifically, the patient’s symptoms are not better explained by a mood disorder with psychotic features or a substance-induced psychotic disorder, as they have occurred in the absence of drug use or medical illness.

• Differential Diagnoses
  • Bipolar Disorder with Psychotic Features (ICD-10 Code: F31.3)

According to DSM-5 criteria, bipolar disorder is characterized by periods of elevated mood, irritability, and energy, with possible psychotic features (Jain & Mitra, 2023). Although the patient displays manic symptoms, the psychotic symptoms occur even when the mood is not elevated, ruling out bipolar disorder with psychotic features.

• Schizophrenia (ICD-10 Code: F20.9)

DSM-5 criteria for schizophrenia include delusions, hallucinations, disorganized speech, and functional impairment lasting for at least six months (Hany et al., 2024). The patient’s mood symptoms of paranoia and mood instability are central to the presentation, indicating schizoaffective disorder rather than schizophrenia, where mood disturbance is not typically a primary feature.

• Major Depressive Disorder with Psychotic Features (ICD-10 Code: F32.3)

According to DSM-5 criteria, major depressive episodes with psychotic features include persistent depressive mood and psychotic symptoms such as delusions and hallucinations (Bains & Abdijadid, 2023). The patient’s mood is not consistently depressive, and the psychotic features are more prominent during periods of psychosis, suggesting schizoaffective disorder rather than depression with psychotic features.

P: Plan

• Treatment Plan:

The treatment plan will involve treatment of the psychotic symptoms as well as the mood symptoms. Antipsychotic medications along with mood stabilizers will be initiated in combination to counter the symptoms of the patient. Also, the patient will be referred to psychotherapy to get better insight into their illness and lessen the severity of psychotic symptoms.

Social support and education will be necessary to address his social functioning and treatment adherence (Jameel et al., 2020). Cognitive-behavioral therapy (CBT) will also be considered to work with any cognitive distortions that relate to delusions and hallucinations.

• Medications:

The medication regimen entails the use of Olanzapine, 10 mg PO OD, ideally in the evening, to minimize the sedation-related adverse effects in the treatment of psychotic symptoms, such as auditory hallucinations and paranoia (Thomas & Saadabadi, 2023). Besides this, the prescription of Lithium Carbonate, 600 mg PO OD in the evening, will be done to stabilize mood and avoid manic outbursts related to schizoaffective disorder.

According to Ghiasi et al. (2024), Lorazepam, 1 mg PO PRN for anxiety and agitation, will also be administered to the patient, with no more than 3 mg daily being used to address short-term symptoms of agitation. Olanzapine is an atypical antipsychotic that treats psychotic symptoms and mood stabilization, and Lithium focuses on manic episodes. Until the antipsychotic and mood stabilizer kicks in, Lorazepam will be administered to treat acute anxiety. The treatment plan will be changed according to the patient’s response and its side effects.

• Follow-Up:

A follow-up will be scheduled in two weeks to evaluate the primary response to the medication and examine the side effects, particularly sedation, weight gain, or metabolic disturbance. Psychiatric follow-ups will be done monthly to assess the stability of mood, the effectiveness of medication, and new symptoms, as well as monitor adverse effects such as metabolic problems. Follow-ups will be done regularly to address the effects of the drugs, especially on the weight, glucose, and lipid profiles (Schneider-Thoma et al., 2021).

The medication regimen will be adjusted depending on the patient’s treatment tolerance and side effects. A long-term treatment plan will be formulated to encompass continuous psychotherapy and possible modification of pharmacologic therapy to reflect the changing aspects of schizoaffective disorder so that the patient’s condition can continue to be stabilized and managed in the long run.

Rationale

• Justification for Treatment Plan:

The treatment plan relies on the existing evidence that acknowledges the effectiveness of atypical antipsychotics, such as Olanzapine, and mood stabilizers, such as Lithium, in treating schizoaffective disorder. Olanzapine is effective in treating the psychotic and mood symptoms of the illness, and Lithium has shown good evidence in stabilizing mood and the prevention of manic episodes (Chokhawala et al., 2024). This condition is best treated with a combination of medications and psychotherapy, which has been shown to restore functioning and less severe symptoms.

References

Bains, N., & Abdijadid, S. (2023, April 10). Major depressive disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

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

Ghiasi, N., Bhansali, R. K., & Marwaha, R. (2024). Lorazepam. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532890/

Hany, M., Rehman, B., Azhar, Y., & Chapman, J. (2024, February 23). Schizophrenia. NIH.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539864/

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

Jameel, H. T., Panatik, S. A., Nabeel, T., Sarwar, F., Yaseen, M., Jokerst, T., & Faiz, Z. (2020). Observed social support and willingness for the treatment of patients with schizophrenia. Psychology Research and Behavior Management, 13(1), 193–201. https://doi.org/10.2147/PRBM.S243722

Schneider-Thoma, J., Kapfhammer, A., Wang, D., Bighelli, I., Siafis, S., Wu, H., Hansen, W.-P., Davis, J. M., Salanti, G., & Leucht, S. (2021). Metabolic side effects of antipsychotic drugs in individuals with schizophrenia during medium- to long-term treatment: Protocol for a systematic review and network meta-analysis of randomized controlled trials. Systematic Reviews, 10(1). https://doi.org/10.1186/s13643-021-01760-z

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

Wy, T. J. P., & Saadabadi, A. (2023, March 27). Schizoaffective disorder. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK541012/

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For the SOAP Note Assignment: You will document a SOAP note on a client using the Focused SOAP Note Template provided. Select a pediatric/adult/geriatric client who presented with a psychotic disorder.

The assignment has the following requirements:

Focused SOAP Note

• Develop a Focused SOAP Note on a client using the template provided in these instructions
• You must add a title page and reference page. The title page and reference page must be in APA format.
• Include at least three peer-reviewed resources published within the last five years to support your assessment, diagnosis, and treatment planning.
  

  SOAP Note: Schizoaffective Disorder, Bipolar Type

Criteria

Patient Demographic Information

Submits demographic information as specified on the SOAP Note Template.

Chief Complaint

Chief compliant is present and placed in quotation marks to indicate the client’s words.

Review of Systems

A full review of systems pertaining to the patient’s complaint/s is present

Current Medications

Current medications are present including the name, dose, route, and frequency.

Subjective Information

All subjective information is documented appropriately and thoroughly

Objective Information

A focused exam related to the client’s chief complaint is presented. A full mental status exam is documented.

Assessment

This includes DSM-V-TR diagnosis/diagnoses, and ICD-10 code/s. Assessment data/diagnosis must correspond to the chief complaint and subjective information given by the patient

Plan

Must include full treatment plan (pharmacological, non-pharmacological treatments, patient education, referrals, laboratory testing, and follow-up). A rationale is required to support your treatment plan based on the diagnosis.

APA Format and References

A title page and reference page in APA format must be included. The APA 7th edition should be used. References should be published within the last five years.