Bipolar Disorder Recitation SOAP Note.docx - Bipolar...

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Bipolar Disorder Recitation SOAP Note Assessment: 1. Bipolar Disorder: Uncontrolled. Patient is having manic episodes. Patient has noticeable change from usual behavior such as inflated self-esteem yelling “don’t you dare tell me what to do! I own this neighborhood and every building therein. Woe unto you!”, decreased need for sleep, more talkative than usual. He has been non- adherent to lithium causing manic episodes, patient needs new optimized and individualized therapy. Patient’s lithium levels are low at < 0.1 mmol/L. According to Canadian Network for Mood and Anxiety Treatments, Quetiapine is good first line agent with level 1 evidence in treating acute depression, prevention of any mood episode, prevention of depression and mania, and treating acute mania. Also, according to Frye MA. N Engl J Med 2011;364:5 1-9, efficacy of Quetiapine as monotherapy in treating bipolar depression confirmed by 4 eight week trials in which Quetiapine was superior to both lithium and paroxetine and has a less risk of mania when compared to paroxetine. The patient is currently on lithium carbonate 600 mg PO BID and venlafaxine ER 150 mg PO daily over two weeks. Goals of Therapy: Reduce the frequency and severity of manic episodes, prevent recurrence and relapse of manic episodes and depressive episodes, and Improve quality of life 2. Hypertension: Uncontrolled. Patient’s current blood pressure is 148/92 mmHg which is not at goal of < 130/80 mmHg. Per the 2017 AHA Guidelines for high BP in adults, both pharmacologic and non-pharmacologic therapy should be initiated. Pharmacologic therapy should include two anti- hypertensive medications from two different classes such as ACE, thiazide diuretic or CCB. Patient is currently not taking any medications to control his blood pressure. Goals of therapy: Reduce and maintain blood pressure to ≤ 130/80 mmHg per AHA/ACC, Reduce morbidity and mortality to improve quality of life, Prevent cardiac complications, including MI and stroke, reduce drinks to < 2 drinks/day (males). 3. Dyslipidemia: uncontrolled Patient has high LDL of 130 mg/dL, high total cholesterol of 240 mg/dL, and high triglycerides of 215 mg/dL. Per the AHA/ACC guidelines, LDL levels should be reduced to < 100 mg/dL, total cholesterol levels < 200 mg/dL, and triglyceride levels < 150 mg/dL.

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