NU580 SOAP Note

Student Name

Purdue University Globle 

NU580 FNP II – Primary Care of Children and Adolescents’ Health

Prof. Name

Date

NU580 SOAP Note: Pediatric Bipolar Disorder Evaluation in a Child With Autism Spectrum Disorder

Children who present with severe mood swings, impulsive behaviors, emotional dysregulation, sleep disturbances, and suicidal statements require immediate psychiatric assessment to determine the underlying cause. In this case, the patient’s clinical presentation is most consistent with bipolar disorder, while autism spectrum disorder (ASD) remains an important coexisting condition that influences her emotional and behavioral functioning. Early diagnosis, comprehensive evaluation, family education, and referral to child psychiatry are essential to improve long-term outcomes and ensure patient safety.

Patient Information

• Patient Name: Amber Renee Carter

• Encounter Number: 1

• Date of Encounter: ________

• Age: 7 years

• Sex: Female

Chief Complaint

Amber states, “I’m mad. I’m really angry.”

History of Present Illness

Amber Renee Carter is a 7-year-old female who presented to the clinic with her stepmother after being referred from Hurley Hospital Emergency Department. The referral followed a serious behavioral incident in which Amber jumped out of her bedroom window during an episode of intense emotional distress.

According to her stepmother, Amber has experienced emotional and behavioral outbursts for approximately two years, with symptoms becoming significantly worse since the beginning of the current school year. During these episodes, she becomes extremely angry, difficult to calm, and demonstrates impulsive behaviors that create safety concerns.

Amber also reports significant sleep disturbances. She struggles to fall asleep, awakens multiple times during the night, has difficulty returning to sleep, frequently attempts to leave her bed during nighttime hours, and often oversleeps in the morning. Her energy levels fluctuate considerably throughout the day.

During episodes of severe frustration, Amber has expressed thoughts about wanting to die or hurting others. Although these suicidal statements are concerning, there is no history of suicide attempts. Her symptoms, combined with a family history of mental illness and longstanding behavioral concerns, warrant further psychiatric evaluation.

Current Medications

The patient is not currently taking any prescribed or over-the-counter medications.

Allergies and Medication Intolerances

Amber reports no known drug allergies and denies any medication intolerances.

Past Medical History

Amber was diagnosed with autism spectrum disorder (ASD) at two years of age.

She has no history of:

• Chronic medical conditions

• Major traumatic injuries

• Previous hospitalizations

• Surgical procedures

Family History

Amber’s biological mother has a history of an unspecified psychiatric disorder. Although the exact diagnosis is unknown, the presence of a possible hereditary mood disorder increases the likelihood of bipolar disorder and supports further psychiatric assessment.

Social History

Amber currently lives with her father and stepmother in a supportive home environment.

Additional social history includes:

• No alcohol use by the patient

• Parents report only occasional alcohol consumption

• Family occasionally drinks a glass of wine with dinner

Review of Systems

General

The review of systems is positive for:

• Behavioral outbursts

• Severe anger

• Emotional dysregulation

• Sleep disturbances

• Fluctuating energy levels

Cardiovascular

The patient denies:

• Chest pain

• Palpitations

• Orthopnea

• Paroxysmal nocturnal dyspnea

• Peripheral edema

Respiratory

The patient denies:

• Shortness of breath

• Wheezing

• Hemoptysis

• History of pneumonia

• Tuberculosis exposure

Gastrointestinal

The patient denies:

• Abdominal pain

• Nausea

• Vomiting

• Constipation

• Diarrhea

• Hepatitis

• Eating disorders

• Peptic ulcers

• Black or tarry stools

Neurological

The patient denies:

• Syncope

• Seizures

• Weakness

• Paralysis

• Paresthesia

• Loss of consciousness

Psychiatric

The patient reports:

• Severe anger episodes

• Impulsive behaviors

• Difficulty sleeping

• Suicidal statements during emotional escalation

She denies any previous psychiatric diagnosis other than autism spectrum disorder.

Objective Findings

Vital Signs

Physical Examination

General Appearance

Amber appears well-developed, well-nourished, alert, and appropriately oriented. She is in no acute physical distress and ambulates normally.

Skin

Skin examination reveals:

• Normal coloration

• No rashes or lesions

• No jaundice

• Pink nail beds

• No cyanosis or clubbing

HEENT

Examination findings include:

• Normocephalic, atraumatic head

• Pupils equal, round, and reactive to light

• Extraocular movements intact

• Normal conjunctiva and sclera

• Patent ear canals with normal tympanic membranes

• Pink nasal mucosa with normal turbinates

• Moist oral mucosa

• No pharyngeal erythema or exudate

• Supple neck with full range of motion

• No cervical lymphadenopathy

• No thyroid enlargement

Cardiovascular

Cardiac assessment demonstrates:

• Regular rate and rhythm

• Normal S1 and S2

• No murmurs

• No rubs or gallops

• Capillary refill approximately two seconds

• Strong peripheral pulses

• No edema

Respiratory

Respiratory examination is normal with clear breath sounds bilaterally and no evidence of respiratory distress.

Gastrointestinal

Abdominal examination reveals:

• Active bowel sounds in all quadrants

• Soft, non-tender abdomen

• No hepatosplenomegaly

Musculoskeletal

Musculoskeletal examination demonstrates:

• Full range of motion

• Normal movement of all extremities

• No joint swelling or deformity

Neurological

Neurological findings include:

• Clear speech

• Normal muscle tone

• Stable posture

• Normal gait

• Alert and oriented

Laboratory Results

The following laboratory studies are within normal limits:

• Basic Metabolic Panel (BMP)

• Complete Blood Count (CBC) with differential

Assessment

Differential Diagnosis

Several psychiatric conditions should be considered based on Amber’s symptoms.

Autism Spectrum Disorder (ASD)

Autism spectrum disorder is a lifelong neurodevelopmental disorder characterized by impaired social communication, repetitive behaviors, restricted interests, and difficulty adapting to changes in routine. Children with ASD often experience challenges with emotional regulation, which can contribute to behavioral outbursts.

Amber has a confirmed diagnosis of ASD established during early childhood. While ASD explains some behavioral symptoms, it does not fully account for her severe mood instability and sleep disruption.

Bipolar Disorder

Pediatric bipolar disorder is characterized by recurrent episodes of mood instability that may include mania, hypomania, depression, or mixed episodes. Common symptoms include:

• Extreme irritability

• Mood swings

• Increased energy

• Reduced need for sleep

• Impulsivity

• Emotional outbursts

• Risk-taking behaviors

Amber’s persistent irritability, impulsive behaviors, fluctuating energy levels, significant sleep disturbance, suicidal statements, and possible family history strongly support bipolar disorder as the leading diagnosis.

Childhood-Onset Schizophrenia

Childhood schizophrenia is an uncommon psychiatric disorder characterized by psychotic symptoms and progressive functional decline.

Typical symptoms include:

• Hallucinations

• Delusions

• Disorganized thinking

• Social withdrawal

• Declining academic performance

Amber currently shows no evidence of psychosis, making schizophrenia less likely. However, continued psychiatric monitoring is appropriate because childhood psychiatric disorders may evolve over time.

Primary Diagnosis

Bipolar Disorder

The patient’s presentation is most consistent with bipolar disorder based on the following clinical findings:

• Severe mood instability

• Persistent anger and irritability

• Significant sleep disturbances

• Fluctuating energy levels

• Impulsive behaviors

• Suicidal statements during emotional crises

• Family history suggesting possible genetic susceptibility

Current evidence suggests that both genetic predisposition and environmental stressors contribute to the development of pediatric bipolar disorder.

Plan and Recommendations

Medication Management

No psychiatric medications were initiated during this visit pending comprehensive psychiatric evaluation.

Non-Pharmacological Interventions

The patient and guardian were advised to:

• Maintain a consistent bedtime routine.

• Ensure adequate sleep, as sleep deprivation may worsen mood symptoms.

• Encourage a balanced diet rich in fruits, vegetables, whole grains, and lean protein.

• Monitor mood, sleep, energy levels, and behavioral changes.

• Maintain structured daily routines to improve emotional regulation.

Safety Education

The family was instructed to seek immediate emergency medical attention if Amber:

• Expresses active suicidal intent

• Develops a suicide plan

• Threatens to harm others

• Demonstrates increasingly dangerous impulsive behaviors

• Experiences rapidly worsening psychiatric symptoms

Recommended Screening Tool

The Conners Comprehensive Behavior Rating Scale (CBRS) is recommended to evaluate:

• Emotional regulation

• Behavioral concerns

• Attention-related symptoms

• Functional impairment

• Comorbid psychiatric conditions

Parent and Caregiver Education

Education focused on:

• Recognizing symptoms of pediatric bipolar disorder

• Identifying early warning signs of mood episodes

• Understanding the importance of early intervention

• Maintaining ongoing psychiatric follow-up

• Supporting emotional regulation through consistent routines

Referrals

Referral is recommended to a Child and Adolescent Psychiatrist for comprehensive diagnostic evaluation and development of an individualized treatment plan.

Follow-Up

Follow up as clinically indicated or sooner if symptoms worsen, new safety concerns arise, or behavioral changes become more severe.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.; DSM-5-TR). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

Esposto, E., Nastro, F. F., Lorenzo, G. D., & Ribolsi, M. (2023). Navigating the intersection between autism spectrum disorder and bipolar disorder: A case study. Journal of Psychopathology. https://www.jpsychopathology.net/

NU580 SOAP Note

Petlovanyi, P., & Tsarkov, A. (2020). Child schizophrenia: Theory and practice. European Journal of Medical and Health Sciences, 2(1). https://doi.org/10.24018/ejmed.2020.2.1.165