Criteria

Clinical Notes

Subjective

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History, Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”.

Objective

This is where the “facts” are located. Include relevant labs, test results, vitals, and physical exam if performed. Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Plan

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.

Criteria

Clinical Notes

Subjective

Chief complaint: The 26-year-old patient is worried that recent legal issues regarding drunk-driving are fuelled by his psychiatric symptoms.

HPI- The legal issues happened several months ago. He reports that the symptoms started when he started taking SSRI for depression and generalized anxiety disorder symptoms. When he started on SSRIs, he lost anxiety, fear, and avoidance. However, he became unusually talkative, had racing thoughts, and was distractible, hyperactive, and impulsive. He also reported decreased need for sleep. The patient exhibited grandiosity, in which he felt invincible and that the law do not apply to him.

Past Medical History: Patient has experienced major depressive episodes as a teenager. His symptoms have included insomnia, despondent thoughts, depressed mood, and low interest in activities, poor energy, and impaired cognition. The depressive episodes have been incapacitating and affect his school and work.

The patient has symptoms of social anxiety characterized with anticipatory anxiety, and nervousness around people.

Social History: the patient reports excessive alcohol use. He has few friends, but his family is supportive.

ROS noncontributory

Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History, Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative with the exception of…”.

Objective

Vitals:

This is where the “facts” are located. Include relevant labs, test results, vitals, and physical exam if performed. Include MSE, risk assessment here, and psychiatric screening measure results.

Assessment

Dx. Bipolar disorder I (ICD 10-F31.1)

According to DSM-IV, diagnosis of bipolar type I requires the presence of manic episode of at least 1 week’s duration that cuases significant impairment in social functioning or work or causes hospitalization.Maniac episodes are characterized by mood disturbance including irritability, grandiosity, reduced need for speech, excessive talking, and racing thoughts (Post, et al., 2019). A patient must experience 5 of the following symptoms of major depressive episodes; depressed mood, reduced pleasure or interest in almost all activities, hypersomnia or insomnia, loss of energy, or feeling of worthlessness.

While the recent the recent episode is associated with SSRIs, the patient history of incapacitating depressive episodes, social anxiety, and these symptoms are present regardless of the affective state.

Differential diagnoses include:

1. Anxiety disorder (ICD 10: F41.9) – the patient presents with social phobias, fear of public places, and panic disorder. Anxiety disorder often mimics or co-occurs with bipolar disorder.

2. Personality disorders (F60.9)- individuals diagnosed with personality disorders are susceptible to depression and substance use disorders. The patient has a history of major depressive disorders and alcohol abuse.

Include your findings, diagnosis and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.

Plan

Work up to consider include:

Complete blood count with differential-to rule out anemia as the cause of depression in bipolar disorder.

Erythrocyte sedimentation rate (ESR)-to rule out underlying disease processes such as lupus.

Thyroid test-to rule out hyperthyroidism and hypothyroidism

Substance and alcohol screening.

Patient will be prescribed lithium carbonate,300 mg orally 2 times a day. The prescription will be titrated based on blood levels and tolerance. Lithium is the first-line mood stabilizer for bipolar disorder. It is associated with significant improvement in 40-80% of patients after 2-3weeks of treatment for mania. For the depression episode, the patient will be prescribed laurasidone. Lithium also reduces the risk of suicide.

The treatment plan will also constitute psychosocial treatment, including psychoeducation, and interpersonal and social rhythm therapy.

Bipolar management requires long-term monitoring. Therefore, the patient follow-up schedule will be set at 4 weeks.

Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options and complimentary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.