SOAP Note for Mania Case Study

SOAP Note for Mania Case Study

Subjective

Chief Complaint (Patient’s Own Words):

I have been working hard for this company and finally discovered how to treat cancer. My GP referred me here to discuss it comprehensively.”

People Present for Appointment:

Mr. John Riley, who is the patient, came for the appointment by himself.

Patient Demographics:

Mr. John Riley is a middle-aged male who works as a car mechanic (he is employed).

History of Present Illness (HPI):

John Riley shows signs of a manic episode, which include increased energy, insomnia, grandiosity, and paranoid ideas (Chakrabarti & Singh, 2022). It has been mentioned that the symptoms had begun over the past week, and the severity seems to have significantly escalated lately. He has been obsessed with finding the ‘cure for cancer’ using arbitrary methods of numbers and charts. Because of his perception that he has much energy, he does not get tired and has reduced the amount of sleep he gets. John also complains of hearing voices, saying that “God speaks to him,” telling him how marvelous he is and how well he is doing his work. Despite such signs, John appears to have no first-hand knowledge of his state of affairs, and he boasts about feeling great and ignores all the issues his coworkers and GP have raised with him.

Psychiatric Review of Systems (ROS):  

1. Mood: Elated and expansive.
2. Sleep: Severely impaired; the patient (John) reports no need for sleep.
3. Energy: John displays excessive energy, often to the point of restlessness.
4. Appetite: Not reported.
5. Concentration: significantly impacted by the racing thoughts concerning his delusional beliefs and ideas.
6. Thought Process: Disorganized, focused on delusional content (cure for cancer).
7. Thought Content: Grandiose delusions, auditory hallucinations.
8. Insight/Judgment: Fails to recognize the severity of his condition.

Medical Review of Systems:

John completely disclaims having any issue with his physical aspect of health or any concern in the recent past. No serious medical conditions were said to have been present.

Family History:

John does not disclose any information of any familial predispositions to either psychiatric or major medical conditions.

Patient Medical History:

No significant medical history was reported.

Patient Psychiatric History:

There are no records that John had psychiatric problems, nor did he receive psychiatric treatment before in his life.

Social History:

John works as a car mechanic. He reports that he is smarter than all the other employees and does not have many people to give him the much-needed social support.

Trauma History:

No reported trauma history.

Substance Use History:

John also adamantly states that he has never used alcohol or recreational substances, both currently or in the past.

Objective:

Mental Status Examination (MSE):

1. Appearance: John looks rather scruffy but has a vibrant body language.
2. Behavior: He fidgets, twists in his chair, consistently switch focus and always returns to his idea about the cure for cancer.
3. Speech: Often starts acting pressured, rushes through information, speaks side topics, and often needs a reminder.
4. Mood: Euphoric and expansive.
5. Affect: Labile and reactive.
6. Thought Process: Disorganized, circumstantial, and tangential.
7. Thought Content: Grandiosity (Mr. John believes he can cure cancer and that God is telling him what to do). John says he has auditory symptoms whereby he hears God telling him his work is fantastic.
8. Perception: Auditory hallucinations (hearing God).
9. Insight: Poor; John does not realize that he is psychotic and that these thoughts and actions are manifestations of a psychiatric disorder.
10. Judgment: Impaired; John shows ineffective decision-making and prioritization; he would rather spend his time on delusional material than his health.
11. Cognition: Not formally evaluated. However, his thought process and behavior suggest weaknesses in attention and focus.
12. Orientation: John is oriented to person, place, and time.

Vital Signs:

None is provided in the case study.

Physical Assessment:

Not relevant to the current case.

Lab Results:

None is available in the case study.

Risk Assessment:

1. Suicide Risk: Low; John had no such feeling and showed no desire for suicide attempts through his speech but seemed to be primarily preoccupied with his delusional ideas.
2. Homicide Risk: Low; no evidence of homicidal ideation.

• Other Risks: Lack of sleep, which increases the risk of self-neglect, grandiosity, and possible harm from untreated mania.

Assessment:

Biopsychosocial Formulation:

1. John Riley, a middle-aged man, exhibits signs of a manic episode: elated feelings, things feeling important and great, racing thoughts, inability to sleep, and hearing things others cannot. While he claims that he does not have genetic vulnerabilities or any family history of mental illness, it cannot be stated that this is true. This is because John has had considerable difficulty accepting the delusions as false and has a limited understanding of his problem. The presented symptoms might be aggravated by psychosocial factors, such as job-related demands and an absence of social support in his case. All these factors make the clinical presentation of the disease rather intricate and necessitate an integrated strategy for assessment and management. John’s case nicely illustrates many of the issues associated with acute manic episodes and their management, and the lack of insight that some patients may have is one of the key issues (Luo et al., 2019). In patient care planning, John will require treatment addressing both the presenting complaints and the possible underlying psychosocial causes.
2. According to the medical history, the patient is not suffering from any diseases that would cause him to exhibit these mannerisms. Nonetheless, if he continues not to sleep, this might have some implications for his physical health.

Three Differential Diagnoses:

1. Bipolar I Disorder, Current Episode Manic with Psychotic Features (Primary Diagnosis): John fits perfectly into the mania episode; he was grandiose, had elevated energy levels, pressured speech, and lack of sleep. It also includes delusions that distort the regular perception of the real world. The option of auditory stimuli also indicates paranoid symptoms in addition to manic episodes. The presence of manic symptoms along with psychotic features significantly supports the diagnosis of a manic episode that can be associated with bipolar disorder or another mood disorder with psychotic symptoms (Fu-I et al., 2019).
2. Schizophrenia Spectrum and Other Psychotic Disorders: As less likely though, John’s symptoms of persecutory delusions and hallucination suggest a psychotic disorder. It becomes more important if the subsequent assessments reveal the continuous presence of psychotic symptoms. If there are other reasons for the symptoms, then other conditions should be suspected; however, if the symptoms persist on a chronic basis, the client may be suffering from a psychotic disorder (Parker et al., 2020). More evaluation and follow-up over time will enable a proper diagnosis and treatment intervention.

• Substance/Medication-Induced Psychotic Disorder: Even though John stated that he does not abuse substances, performing a substance-specific toxicology test is required to exclude other substance abuse-related possibilities. The extended testing procedure would give an independent confirmation or otherwise of John’s self-claimed non-use of substances (Fu-I et al., 2019). Unless screening for substance use is done, it becomes impossible to rule out substances in their present state or manifestations.

Primary Diagnosis:

Bipolar I Disorder, Current Episode Manic with Psychotic Features (DSM-5 code: 296.44).

Medical Diagnoses:

None were reported in the case study.

Obstacles to Treatment:

John can be seen to lack good insight about his condition, and his delusional symptomatic presentation may make him less willing to seek treatment.

Plan:

Pharmacologic Treatment:

1. Prescribe mood stabilizer Lithium at an initial dose of 300 mg daily and increase depending on response and side effects. Lithium, however, needs frequent blood level surveillance to maintain therapeutic concentrations and prevent toxic effects (Kishi et al., 2022).
2. Prescribe some antipsychotic medicine (e.g., Olanzapine, 5 mg at night) to manage the psychotic features to regulate John’s state of mind.

• Medication Education: John needs to be enlightened on the consequences of non-compliance to mood stabilizers and antipsychotic medications, the necessity of blood tests when taking Lithium, and possible complications, including sedation, increased weight, and shakes (Kishi et al., 2022).

Non-pharmacologic Treatment:

1. Psychoeducation: John and his family should learn about bipolar disorder, especially how to go about a manic episode.
2. Cognitive Behavioral Therapy (CBT): Once anchored, CBT may assist in further resolving other symptoms that include grandiosity, delusions, and impaired insight that John presents with.

Laboratory Orders:

1. Pre-lithium blood tests like complete blood count, renal function test, thyroid profile, and serum electrolyte test to look for any relative contraindications (Kishi et al., 2022).
2. During the treatment, periodic checkups of Lithium levels in the blood and thyroid function.

Referrals:

1. Consult a psychiatric social worker to help cope with psychosocial demands and to guide you on how to find appropriate support in society.
2. Patients are referred to individual therapy to help manage their symptoms as they continue their day-to-day activities (Kishi et al., 2022).

Follow-up: 

1. Subsequent appointment in 1 week to evaluate the efficacy of administered medication, any adverse effects, and symptom control.
2. The follow-ups should be continuous and include assessments of mood status, medication compliance, and safety issues.

Rationale for Treatment Plan:

The use of Lithium as a mood stabilizer and Olanzapine as an antipsychotic are both prescribed commonly in cases of manic episodes with psychotic symptoms. Lithium is chosen because of its ability to stabilize mood, while Olanzapine treats psychotic manifestations (Kishi et al., 2022). Where possible, it is important to constantly observe the patient and ensure that symptoms of mania do not worsen and any potentially dangerous behaviors arising from untreated mania, such as sleeplessness, are avoided.

References

Chakrabarti, S., & Singh, N. (2022). Psychotic symptoms in bipolar disorder and their impact on the illness: a systematic review. World journal of psychiatry, 12(9), 1204.

Fu-I, L., De S Gurgel, W., Caetano, S. C., Machado-Vieira, R., & Wang, Y. P. (2019). Psychotic and affective symptoms of early-onset bipolar disorder: an observational study of patients in first manic episode. Brazilian Journal of Psychiatry, 42(2), 168–174. https://doi.org/10.1590/1516-4446-2019-0455

Kishi, T., Ikuta, T., Matsuda, Y., Sakuma, K., Okuya, M., Nomura, I., … & Iwata, N. (2022). Pharmacological treatment for bipolar mania: a systematic review and network meta-analysis of double-blind randomized controlled trials. Molecular psychiatry, 27(2), 1136-1144.

Luo, C., Chen, H., Zhong, S., Guo, H., Li, Q., Cai, W., De Girolamo, G., Zhou, J., & Wang, X. (2019). Manic episode, aggressive behavior and poor insight are significantly associated with involuntary admission in patients with bipolar disorders. PeerJ, 7, e7339. https://doi.org/10.7717/peerj.7339

Parker, G., Spoelma, M. J., Tavella, G., Alda, M., Hajek, T., Dunner, D. L., O’Donovan, C., Rybakowski, J. K., Goldberg, J. F., Bayes, A., Sharma, V., Boyce, P., & Manicavasagar, V. (2020). The bipolar disorders: A case for their categorically distinct status based on symptom profiles. Journal of Affective Disorders, 277, 225–231. https://doi.org/10.1016/j.jad.2020.08.014

SOAP Note for Mania Case Study

CLICK HERE TO ORDER A PLAGIARISM-FREE PAPER