Chief Complaint
| What brought you here today…? (Put this in quotes.) | “I am here for a routine follow-up to ensure my bipolar disorder remains stable.”
|
History of Present Illness
| Depression symptoms: Can you describe your depression symptoms? What makes the depression better, what makes the depression worse? Does the depression, come and go? | Sarah reports no current symptoms of depression. Previously, she experienced severe depressive episodes characterized by feelings of hopelessness, fatigue, and loss of interest in activities. Her depressive episodes have been managed effectively with her current medication regimen. |
| Anxiety: Does the anxiety come and go or is there all the time? Does anything make the anxiety worse or better? Do you go into panic? If so, how often and how long does it usually last? | Sarah experiences occasional anxiety, which is managed with clonazepam as needed. Her anxiety tends to increase during high-stress periods like exams. She uses mindfulness techniques to manage it effectively. |
| Mood swings: Do your moods go up and down? If so, can you tell me more about a typical mood swing? |
Sarah’s mood has been stable for the past 8 months. She previously experienced severe manic and depressive episodes but has been euthymic with her current treatment plan. |
| Anger/irritability: Do you get angry more than you should? How do you act when you get angry? | Sarah reports occasional irritability, especially during stressful situations. She uses cognitive-behavioral techniques to manage her anger and does not display excessive anger. |
| Attention and focus: Do you have trouble concentrating or staying on track? | Sarah occasionally struggles with concentration during high-stress periods but manages well overall with her therapy and coping strategies. |
| Current self-harm, suicidal/homicidal ideations: Do you currently or have you recently thought about hurting yourself? If so, do you have a plan of hurting yourself? | Sarah denies any current or recent thoughts of self-harm or suicidal/homicidal ideations. |
| Hallucinations: Do you ever hear or see anything that other people may not hear and/or see? | Sarah denies experiencing any auditory or visual hallucinations. |
| Paranoia: Do you feel like people are talking about your or following you? | Sarah denies feelings of paranoia. |
| Sleep: Do you have trouble falling or staying asleep? How long does it take you to fall asleep? Once you get to sleep, do you stay asleep all night or are you up and down throughout the night? | Sarah maintains a consistent sleep schedule and does not have trouble falling or staying asleep. She practices good sleep hygiene and sleeps through the night. |
Past Psychiatric History
Family History
| Include parents, siblings, grandparents if applicable/known; pertinent mental health history. | No significant family history of mental health disorders. |
Personal/Social History
| Education, marital status, occupation, work history, and legal history | Education: University student, majoring in psychology.
Marital status: Single. Occupation: Full-time student. Work history: No significant work history due to full-time student status. Legal history: No legal issues. |
Substance Abuse History
| Do you currently or in the past used any illegal drugs? If so, what did you use? If currently using drugs, how much do you use? When was the last time you used? | Sarah denies current or past use of illegal drugs. |
| Do you currently or in the past had an issue with alcohol abuse? If so, when was the last time you drank? Do you ever pass out when you drink? Has your drinking been a problem for you in the past? | Sarah drinks socially but does not have a history of alcohol abuse |
| Do you currently smoke cigarettes or vape? | Sarah does not smoke cigarettes or vape |
| Do you smoke marijuana? | Sarah does not use marijuana. |
Medical History
| Medical problems | None reported |
| Previous surgeries | None |
Mental Status Exam
Appearance and Behavior
| Appearance: Gait, posture, clothes, grooming | Well-groomed, appropriate attire for season, good posture |
| Behaviors: mannerisms, gestures, psychomotor activity, expression, eye contact, ability to follow commands/requests, compulsions | Normal psychomotor activity, good eye contact, follows commands well. |
| Attitude: Cooperative, hostile, open, secretive, evasive, suspicious, apathetic, easily distracted, focused, defensive | Cooperative and open. |
| Level of consciousness: Vigilant, alert, drowsy, lethargic, stuporous, asleep, comatose, confused, fluctuating | Alert. |
| Orientation: “What is your full name?” “Where are we at (floor, building, city, county, and state)?” “What is the full date today (date, month, year, day of the week, and season of the year)?” | Fully oriented to person, place, and time. |
| Rapport | Good rapport established. |
Speech
| Quantity descriptors: talkative, spontaneous, expansive, paucity, poverty. | Spontaneous and talkative. |
| Rate: fast, slow, normal, pressured | Normal. |
| Volume (tone): loud, soft, monotone, weak, strong | Normal. |
| Fluency and rhythm: slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic | Clear, with appropriately placed inflections. |
Affect and Mood
| Mood (how the person tells you they’re feeling): “How are you feeling?” | I feel stable and good. |
| Affect (what you observe): appropriateness to situation, consistency with mood, congruency with thought content
· Fluctuations: labile, even, expansive · Range: broad, restricted · Intensity: blunted, flat, normal, hyper-energized · Quality: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable |
Appropriate to situation, congruent with mood.
Fluctuations: Even. Range: Broad. Intensity: Normal. Quality: Euthymic. |
| Congruency: congruent or not congruent mood? | Congruent mood |
Perception
| Paranoia | Denies. |
| Auditory hallucinations | Denies. |
| Visual hallucinations | Denies. |
Thought Content
| Suicidal | Denies. |
| Homicidal | Denies. |
| Delusions (erotomanic, grandiose, jealous, persecutory, and somatic themes?)
· Delusions are fixed, false beliefs. · These are unshakable beliefs that are held despite evidence against it, and despite the fact that there is no logical support for it. · Is there a delusional belief system that supports the delusion? |
Denies any fixed, false beliefs. No erotomanic, grandiose, jealous, persecutory, or somatic themes reported. Sarah does not display a delusional belief system. She is able to acknowledge the possibility of irrational thoughts but does not hold any overvalued ideas. |
| If not a delusion, then could it be an overvalued idea (an unreasonable and sustained belief that is maintained with less than delusional intensity (i.e. – the person is able to acknowledge the possibility that the belief is false)? | Denies |
| Ideas of Reference (IOR): everything one perceives in the world relates to one’s own destiny (e.g., thinking the computer or TV is sending messages or hints). | Denies. She does not perceive that external events are directly related to her own destiny. |
| First rank symptoms: auditory hallucinations, thought withdrawal, insertion and interruption, thought broadcasting, somatic hallucinations, delusional perception, and feelings or actions experienced as made or influenced by external agents | Denies auditory hallucinations, thought withdrawal, insertion, interruption, thought broadcasting, somatic hallucinations, delusional perception, or feelings/actions influenced by external agents. |
| What is actually being said? Does the content contain delusions? | No |
| Are the thoughts ego-dystonic or ego-syntonic? | No |
Thought Form/Process
| What is the logic, relevance, organization, flow, and coherence of thought in response to general questioning during the interview? | Logical and coherent. |
| Descriptors: linear, goal-directed, circumstantial, tangential, loose associations, clang associations, incoherent, evasive, racing, blocking, perseveration, neologisms. | Linear and goal-directed. |
Cognition
| Cognitive testing | No issues noted |
| Education level | University student |
Insight
| What is their understanding of the world around them and their illness? | Good understanding and awareness of her condition. |
| Are they able to do reality-testing (i.e., are they able to see the situation as it really is)? | Good.
Sees the situation as it is in reality |
| Are they help-seeking? Help-rejecting? | Actively engaged in treatment and seeking help. |
Judgement
| What have their actions been? Have they done anything to put themselves or other people at harm? | Safe and responsible behavior. |
| Are they behaving in a way that is motivated by perceptual disturbances or paranoia? |
None reported |
| What is your confidence in their decision making? | I have more confidence that she can make good decisions. |
Medications
| Medical medications (list) | None |
| Psychiatric medications (list) | Lithium: 900 mg/day
Quetiapine: 200 mg/day Clonazepam: 0.5 mg as needed for anxiety |
Psychiatric Medication
Use this template of this table for each medication. Try to use your own words. For example, how would you explain this information to them or their family?
| Brand/generic name | Lithium: 900 mg/day |
| Dose at the time of visit | None |
| Starting dose | 300 mg/day |
| How does this medication work? | Stabilizes mood by balancing neurotransmitters. |
| Major side effects | Mild tremors, increased thirst. |
| Is this medication FDA approved for why the person is using this medication? | Yes, for bipolar disorder |
| Patient education | Importance of regular blood tests to monitor lithium levels. |
| Medication class | Mood stabilizer. |
| Brand/generic name | Quetiapine: 200 mg/day |
| Dose at the time of visit | None |
| Starting dose | 50 mg/day |
| How does this medication work? | Atypical antipsychotic that helps regulate mood. |
| Major side effects | Allergic reactions, Drowsiness, Weight gain, Dry mouth, |
| Is this medication FDA approved for why the person is using this medication? | Yes, for bipolar disorder |
| Patient education | Take at bedtime to minimize drowsiness. |
| Medication class | Atypical antipsychotic. |
| Brand/generic name | Clonazepam: 0.5 mg as needed for anxiety |
| Dose at the time of visit | None |
| Starting dose | 0.25 mg as needed |
| How does this medication work? | Benzodiazepine that helps reduce anxiety. |
| Major side effects | Drowsiness, potential for dependency. |
| Is this medication FDA approved for why the person is using this medication? | Yes, for bipolar disorder |
| Patient education | Use sparingly and only as needed |
| Medication class | Benzodiazepine. |
Psychiatric Diagnosis
| Current diagnosis | Bipolar I Disorder |
| DSM-5 symptom criteria for each diagnosis (write out DSM-5 symptom criteria) | · At least one manic episode characterized by elevated, expansive, or irritable mood and increased goal-directed activity or energy lasting at least one week.
· Symptoms cause significant impairment in social or occupational functioning. · Depressive episodes may include feelings of hopelessness, fatigue, and loss of interest in activities (O’Donnell & Miklowitz, 2020). |
| Did they display/state any symptoms that match the diagnosis? | · Manic Episodes: History of at least one manic episode with elevated mood and increased activity.
· Depressive Episodes: Past severe depressive episodes with hopelessness and fatigue. · Stable on Medication: Currently stable on lithium and quetiapine, indicating effective management of Bipolar I Disorder. |
Billing/Coding
| ICD 10 Code | F31.0 (Bipolar disorder, current episode hypomanic without psychotic features) |
| Billing Code | 90791 – Psychiatric Diagnostic Evaluation |
Treatment Plan
| Medication changes made during visit | None during this visit. |
| Clinical impression | Sarah is stable with good adherence to her treatment plan.
|
| Recommended therapy/support sources for person and the reason why | Continue weekly CBT sessions, monthly family therapy sessions, maintain involvement in mental health advocacy group (Strakowski et al., 2020). |
| Next visit scheduled | Scheduled for 3 months from now for routine follow-up. |
References
O’Donnell, L., & Miklowitz, D. (2020). Current state of evidence-based psychotherapies for bipolar disorder. Bipolar Disorder, 233-266. https://doi.org/10.1093/med/9780190908096.003.0014
Strakowski, S. M., Almeida, J. R., & DelBello, M. P. (2020). Psychopharmacological treatments for bipolar disorder. Bipolar Disorder, 191-232. https://doi.org/10.1093/med/9780190908096.003.0013