Comprehensive i-Human Bipolar II Disorder Case
Study (2026): Full SOAP Note, Detailed Mental
Status Exam, and Medication Titration Plan
PATIENT INFORMATION
,Name: Sarah Thompson
Age: 29
Gender: Female
Ethnicity: African American
Marital Status: Single
Occupation: Marketing executive
Source: Self
Reliability: Good
SUBJECTIVE
Chief Complaint (CC)
“I feel depressed most of the time, but sometimes I get bursts of energy where I don’t sleep and
take on too much.”
History of Present Illness (HPI)
29-year-old female presents with persistent depressive symptoms for 3 months, including:
• Depressed mood most of the day
• Anhedonia
• Fatigue
• Hypersomnia alternating with insomnia
• Poor concentration
• Feelings of worthlessness
• Passive thoughts of “not wanting to wake up,” but denies plan or intent
She reports periodic episodes lasting 4–5 days where she:
• Sleeps 3–4 hours without fatigue
• Feels unusually confident
• Talks rapidly
• Starts multiple projects
• Spends excessively (recent $2,000 credit card debt)
• Becomes more socially outgoing
• No psychosis
These episodes have occurred 4–5 times over the past 2 years and never required hospitalization.
, No history of full manic episode.
Past Psychiatric History
• Diagnosed with Major Depressive Disorder at age 24
• Treated with sertraline 50 mg daily (stopped 1 year ago due to feeling “too energized”)
• No psychiatric hospitalizations
• No suicide attempts
Medical History
• Hypothyroidism (well controlled)
• No seizures
• No head trauma
Medications
• Levothyroxine 75 mcg daily
• No psychiatric medications currently
Allergies
• NKDA
Family History
• Mother: Depression
• Maternal uncle: Bipolar I Disorder
• No family suicide history
Social History
Study (2026): Full SOAP Note, Detailed Mental
Status Exam, and Medication Titration Plan
PATIENT INFORMATION
,Name: Sarah Thompson
Age: 29
Gender: Female
Ethnicity: African American
Marital Status: Single
Occupation: Marketing executive
Source: Self
Reliability: Good
SUBJECTIVE
Chief Complaint (CC)
“I feel depressed most of the time, but sometimes I get bursts of energy where I don’t sleep and
take on too much.”
History of Present Illness (HPI)
29-year-old female presents with persistent depressive symptoms for 3 months, including:
• Depressed mood most of the day
• Anhedonia
• Fatigue
• Hypersomnia alternating with insomnia
• Poor concentration
• Feelings of worthlessness
• Passive thoughts of “not wanting to wake up,” but denies plan or intent
She reports periodic episodes lasting 4–5 days where she:
• Sleeps 3–4 hours without fatigue
• Feels unusually confident
• Talks rapidly
• Starts multiple projects
• Spends excessively (recent $2,000 credit card debt)
• Becomes more socially outgoing
• No psychosis
These episodes have occurred 4–5 times over the past 2 years and never required hospitalization.
, No history of full manic episode.
Past Psychiatric History
• Diagnosed with Major Depressive Disorder at age 24
• Treated with sertraline 50 mg daily (stopped 1 year ago due to feeling “too energized”)
• No psychiatric hospitalizations
• No suicide attempts
Medical History
• Hypothyroidism (well controlled)
• No seizures
• No head trauma
Medications
• Levothyroxine 75 mcg daily
• No psychiatric medications currently
Allergies
• NKDA
Family History
• Mother: Depression
• Maternal uncle: Bipolar I Disorder
• No family suicide history
Social History
