This paper presents a comprehensive psychiatric SOAP note evaluation of a 15-year-old female referred for worsening behavioral and academic difficulties. The case explores a chief complaint of ineffective ADHD medication, and through detailed subjective history, objective findings, and mental status examination, arrives at a primary diagnosis of bipolar II disorder co-occurring with ADHD. Three differential diagnoses — bipolar disorder, ADHD (predominantly inattentive presentation), and major depressive disorder — are systematically evaluated against DSM-5 criteria. The treatment plan includes initiation of lithium carbonate, continuation of methylphenidate (Concerta), and cognitive-behavioral therapy. Patient education on medication risks, adherence, and safety planning is also addressed.
This paper demonstrates evidence-based differential diagnosis: each diagnostic candidate is introduced, matched against established criteria (DSM-5), and systematically accepted or eliminated based on the clinical evidence presented. This method prevents premature diagnostic closure and models the structured reasoning expected of a psychiatric nurse practitioner.
The paper follows the standard SOAP format — Subjective (chief complaint, HPI, medications, ROS), Objective (diagnostic test results), Assessment (MSE and differential diagnoses), and Plan (treatment, education, safety, follow-up). A reflections section bridges the assessment and plan, adding an evaluative layer on pharmacological considerations for a pediatric patient. This structure is commonly required in PMHNP clinical training programs.
CC (Chief Complaint): The client presents accompanied by her mother. The chief complaint, as reported by the mother, is that the client's medications "do not seem to be working." Her grades have been on a consistent downward trend, from As to Bs and currently Ds. Conflicts with her sister and mother at home have escalated to the point that her mother describes her as "mean" and "nasty," and she has lost many of her long-standing friends. The client, for her part, says she has no particular complaints and that her mother is exaggerating.
HPI: The client is a 15-year-old white female referred by her primary care physician (PCP) due to worsening difficulties at school and at home. The client first saw a psychiatrist at the age of 7, when she was evaluated for attention-deficit hyperactivity disorder (ADHD) because of distractibility, impulsivity, and restlessness. After a series of failed behavioral interventions, the client was placed on methylphenidate-based medication at the age of 8. For the next six years, her social life and academic scores improved, and she was much like any other child her age as long as she took her medication.
Over the past year, however, the client has stopped being a bubbly teenager and is moody most of the time. She spends days by herself, locked in her room, and hardly speaks to anyone. During these episodes, she is uninterested in everything, constantly complains that her family and friends do not like her, and sleeps most of the day. Her mother reports that for a week or two the client would be "bubbly," laugh at nearly anything, and enthusiastically help with household chores. She would then sink into a week or so of persistent sadness and irritability, during which she is constantly yelling at her sister and mother to the point that everyone is "walking on eggshells."
At around age 14, her therapist increased her dosage of ADHD medication. The client's family history is pertinent for bipolar disorder (manic-depressive illness); her mother indicates that the client's father, whom the client has never met, was treated with lithium when they were together.
Substance Use: The client denies use of any illicit substances or alcohol.
Medical History:
Current Medications: Concerta 36 mg once daily. The client denies taking any over-the-counter drugs or any medication other than her ADHD medication.
Allergies: No known allergies.
Reproductive History: The client denies contraceptive use or engagement in any form of sexual activity. She reports being on the second day of her menstrual period.
Review of Systems (ROS):
General: Denies chills, fever, weight loss, or recent illnesses.
HEENT: Eyes: no visual loss, double vision, blurred vision, or yellow sclerae. Ears, nose, and throat: no hearing loss, sneezing, congestion, runny nose, or sore throat.
Skin: No itching or rash.
Cardiovascular: No chest pain or discomfort, palpitations, or edema.
Respiratory: No cough, sputum, or shortness of breath.
Gastrointestinal: No abdominal pain or blood; no nausea, vomiting, diarrhea, or anorexia.
Genitourinary: No burning on urination, abnormal color, or hesitancy.
Neurological: Slight headache from time to time; denies dizziness, ataxia, syncope, or numbness/tingling in the extremities; no changes in bladder or bowel control.
Musculoskeletal: No joint pain, back pain, muscle pain, or stiffness.
Hematologic: No signs of bleeding, anemia, or bruising.
Lymphatics: Nodes are of normal size; no history of splenectomy.
Endocrinologic: The client denies cold intolerance, profuse sweating, or heat intolerance. No polydipsia or polyuria.
In conjunction with the physical examination, the clinician ordered a complete blood count to exclude anemia or infection as potential causes of depressive symptoms (Culpepper, 2014). Fasting glucose and lipid assessments were deemed prudent to establish the presence of hyperlipidemia or diabetes and to document baseline values before commencing treatment (Culpepper, 2014). A CT scan was ordered to exclude an organic etiology for mood symptoms — such as multiple sclerosis or a brain tumor — as a possible cause (Brunkhorst-Kanaan et al., 2020). All tests yielded normal results, ruling out anemia, blood infection, hyperlipidemia, diabetes, and brain abnormalities.
Mental Status Examination: The client is a 15-year-old female of average weight and height. She presents dressed appropriately, with her hair neatly pulled back. She is oriented to person and place, and her thought processes are coherent and goal-directed. She appears sad and weary throughout the interview, with some affective constriction. There is no evidence of abnormal motor activity, and her speech is clear and coherent with normal tone and volume. The client denies experiencing hallucinations, psychotic symptoms, and suicidal or homicidal thoughts. Her judgment and insight are intact. During the examination, she expresses that she hates feeling depressed one day and elated the next, and that she cannot predict how she will feel tomorrow.
Diagnostic Impression: Three differential diagnoses can be derived from the subjective and objective information: bipolar disorder, ADHD (predominantly inattentive presentation), and major depressive disorder. The client's symptoms align with major depressive disorder in that she exhibits a depressed or irritable mood for most of the day, loss of interest in activities, hypersomnia, inability to think or concentrate leading to declining academic performance, and feelings of worthlessness. However, a major depressive disorder diagnosis would not account for the alternating depressive and hypomanic episodes the client experiences. A persistent depressive disorder diagnosis may seem plausible given that symptoms have been present for over one year; however, one criterion for persistent depressive disorder is that there must never have been a hypomanic or manic episode (APA, 2013). As such, a depressive disorder diagnosis alone is the least likely of the three differentials.
ADHD is characterized by impulsive behavior, hyperactivity, and poor judgment, which can overlap with symptoms of bipolar disorder (Culpepper, 2014). Inattention in ADHD manifests as lacking persistence, wandering off task, being disorganized, difficulty sustaining focus when such difficulty is not due to defiance or lack of comprehension (APA, 2013). An associated feature of ADHD is impaired academic or work performance, which the client exhibits (APA, 2013). Further, the client meets the requirement that the disorder be present in more than one setting — in this case, both home and school — and that symptoms began prior to age 12.
The client's symptoms meet the criteria for bipolar II disorder, characterized by alternating periods of hypomania lasting at least four days and major depressive episodes (APA, 2013). During the hypomanic phase, the client exhibits inflated self-esteem, an increase in goal-directed activity, elevated energy levels, and is more talkative than usual. During the depressive phase, the client shows symptoms of major depressive disorder, including irritability, loss of interest, hypersomnia, diminished ability to concentrate, and feelings of worthlessness over a period of several weeks (APA, 2013). The client has had ADHD since age 7, and given a family history of bipolar disorder, the most likely diagnosis is bipolar II disorder co-occurring with ADHD. According to Culpepper (2014), symptoms of ADHD and bipolar disorder commonly co-occur.
APA (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association.
Brunkhorst-Kanaan, N., Verdenhalven, M., Kittel-Schneider, S., Vainieri, S., Reif, A., & Grimm, O. (2020). The Quantified Behavioral Test — A confirmatory test in the diagnostic process of adult ADHD. Frontiers in Psychiatry, 11(1), 216–235.
Chiang, K., Tsai, J., Liu, D., Hin, C., Chiu, H., & Chou, K. (2017). Efficacy of cognitive behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. PLOS ONE. doi:10.1371/journal.pone.0176849
Culpepper, L. (2014). The diagnosis and treatment of bipolar disorder: Decision-making in primary care. The Primary Care Companion for CNS Disorders, 16(3). doi:10.4088/PCC.13r01609
FDA (2018). Lithium carbonate: Highlights of prescribing information. Food and Drug Administration. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/017812s033,018421s032,018558s027lbl.pdf
Always verify citation format against your institution’s current style guide requirements.