PTSD SOAP Note Example

Assignment: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD (PTSD SOAP Note Example)

PTSD SOAP Note Example

This extensive psychiatric assessment was of a 27-year-old veteran who served in the military for eight years immediately after high school, completing three long tours in war zones. The client concluded his service as a marine six months ago. He has a fiancée he plans to marry and is utilizing his G.I. Education Bill to attend online accounting classes. The client presents symptoms that indicate possible PTSD attributed to the environmental stressors from the warzone. The patient reports that explosive-like sounds, grilling smells, and traffic jams give him flashbacks of the warzone, and in most instances, this results in nightmares in the subsequent days. He prefers to avoid the stressors as much as possible. The paper discusses the psychiatric examination of the client to improve understanding of PTSD, its development influences, impact on role and functioning, and signs and symptoms (PTSD SOAP Note Example). Assignment: Assessing and Diagnosing Patients With Anxiety Disorders, PTSD, and OCD (PTSD SOAP Note Example). The post includes the Subjective, Objective, Assessment, and Plan sections. 

Comprehensive Psychiatric Evaluation

Patient Initials: P.F.  Sex: Male       Race: White Non-Hispanic    Age: 27

PTSD SOAP Note Example of Subjective:

CC: “My Fiance suggested, well demanded, that I make an appointment.”

HPI: P.F. is a 27-year-old Caucasian man who visits on the recommendation of his fiancé. P.F has served in three tours and has recently left the military. The patient reports having trouble sleeping, nightmares of war experiences, and waking up sweating. He reports that the nightmares are triggered by specific incidents such as explosive-like sounds, grilling smells, traffic jams, and the smell of diesel and helicopters irritating him. P.F reports having nightmares about explosions and the loss of his friends who died after an explosion during his last tour. He also fears disclosing his experiences and nightmares to anyone because they would treat him differently.

Read More on

1. 3 SOAP note objective examples
2. SOAP note Sample for PMHNPs
3. SOAP Notes Assessment Examples | Guide & Outline

Past Psychiatric History:

• General Statement: No Significant psychiatric History
• Caregivers: The fiancé is the patient’s primary caregiver because they live together
• Hospitalizations: No hospitalizations were reported
• Medication trials: B.S. is not under any current psychiatric medication.
• Psychotherapy or Previous Psychiatric Diagnosis: The patient has not been diagnosed with any psychiatric condition in the past.

Substance Current Use and History: The patient does not take alcohol or use illicit drugs.

Family Psychiatric/Substance Use History: The patient lives with his fiancé, whom he reports has no significant psychiatric history. His father is still alive but unwell, suffering from diabetes mellitus, cirrhosis, and HTN. His father is still an alcoholic (PTSD SOAP Note Example) The patient’s grandfather was a veteran and developed depression after his military service, although he has never talked to anyone besides the patient because of related experiences. The patient has a younger brother and older sister with no significant psychiatric history. The patient and his fiancé live in a different state from his parents, and they plan to get married and have kids someday.  

Psychosocial History: After military service, the patient moved away from his family and started living with his fiance’ in a different state, where she got a much better job opportunity. They want to get married and have kids in the future.  

Medical History: Patient reports no significant medical history

• Current Medications: Patient denies any current medications
• Allergies: Patient reports service-connected asthma, seasonal allergies

• Reproductive Hx: The fiancé is the patient’s only sexual partner to whom he plans to get married and have kids.

ROS:

• GENERAL: Patient experiences sleeping difficulty attributed to warzone flashbacks, severe anxiety, and hallucinations.
• HEENT:

Head: Denies headache. Denies dizziness or lightheadedness.

Eyes: Denies blurred vision, difficulty focusing, ocular pain, diplopia, scotoma, peripheral visual changes, and dry eyes. No corrective lenses.

Ears, Nose, Mouth, and Throat: Denies sore throat and difficulty swallowing. Denies hearing changes, earache, ear pressure, or tinnitus. Denies hoarseness, vertigo, sinus problems, epistaxis, dental problems, oral lesions, and nasal congestion.

• SKIN: Patient denies rash, wounds, bruising
• CARDIOVASCULAR: Denies any history of a heart murmur, chest pain, palpitations, dyspnea, activity intolerance, varicose veins, or edema.
• RESPIRATORY: Denies cough. Denies history of respiratory infections, SOB, wheezing, difficulty breathing, exposure to secondary smoke, T.B., and hemoptysis.
• GASTROINTESTINAL: Denies reflux, pyrosis, bloating, nausea, vomiting, diarrhea, constipation, hematemesis, abdominal or epigastric pain, hematochezia, change in bowel habits, food intolerance, flatulence, hemorrhoids.
• GENITOURINARY: Denies urgency, frequency, dysuria, suprapubic pain, nocturia, incontinence, hematuria, and history of stones.
• NEUROLOGICAL: Denies headache, weakness, numbness, tingling, memory difficulties, involuntary movements or tremors, syncope, stroke, seizures, or paresthesia – PTSD SOAP Note Example
• MUSCULOSKELETAL: Denies joint pain and tenderness. The patient denies back pain, muscle pain or cramps, neck pain or stiffness, and changes in ROM.
• HEMATOLOGIC: Denies unusual bleeding or bruising. Denies history of anemia and blood transfusions.
• LYMPHATICS: No lymph node enlargement or tenderness noted.
• ENDOCRINOLOGIC: Denies cold or heat intolerance, polydipsia, polyphagia, polyuria, hair or nail texture, unexplained weight change, changes in facial or body hair, changes in hat or glove size, and use of hormonal therapy.

PTSD SOAP Note Example of OBJECTIVE:

Physical Exam: T- 98.8 P- 86 R 18 B/P 122/7 Ht 5’8 Wt 160lbs

Diagnostic Results: Severe Post-Traumatic Disorder (PTSD).

PTSD SOAP Note Example of ASSESSMENT:

Mental Status Examination:

Appearance: Appears clean and appropriately dressed. Makes good eye contact.

Attitude/interaction: Pleasant and appropriate; no anger or aggressiveness noted

Activity level/behavior: No psychomotor retardation or agitation.

Orientation: Alert and oriented to person, place, and time.

Speech: Clear and fluent, sounds mildly anxious

Thought content/process/perception: Thought content/process is concrete, organized, and logical. No perceptual disturbances are noted or stated by the patient during the assessment.

Mood/affect: Mood is reported as “manic,” appropriate for the situation.

Judgment/insight/cognitive/memory: Proper judgment and insight overall. Remote and current memory intact. No apparent cognitive deficits.

Attention: Noted no difficulty concentrating during the assessment.

Differential Diagnoses:

1. Post-Traumatic Stress Disorder (PTSD):  Posttraumatic stress disorder (PTSD) is a syndrome brought on by experiencing actual or threatened severe harm, sexual assault, or death. PTSD is a frequent condition that develops after a traumatic experience and is one of the significant health issues linked to comorbidity, functional impairment, and a higher death rate when combined with suicidal thoughts and attempts. PTSD is now a part of the new category of Trauma- and Stress-related Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The signs of PTSD include having intrusive thoughts, nightmares, flashbacks, dissociation (loss of self or reality), and an extremely negative emotional (sadness, guilt) and physiological reaction when the traumatic experience is recalled (Mann & Marwaha, 2022). Additional symptoms include difficulty sleeping, concentration, impatience, increased reactivity, startle reaction, hypervigilance, and avoiding traumatic triggers. Additional symptoms include difficulty sleeping, concentration, impatience, increased reactivity, startle reaction, hypervigilance, and avoiding traumatic triggers. The ability to operate in social, occupational, and other spheres is significantly impaired. PTSD was confirmed through the subjective data the patient provided.
2. Acute stress disorder: Acute stress disorder and PTSD share many symptoms. Making the final diagnosis is aided by the onset and persistence of the symptoms. If the symptoms appear for less than a month, acute stress disorder becomes the confirmed diagnosis. Symptoms include palpitations, difficulty breathing, chest pain, headache, stomach pain, nausea, and sweating (Fanai & Khan, 2020). This diagnosis was refuted because symptoms have existed for more than one month.
3. Depression: Before formulating a treatment plan, it may be necessary to assess the patient for any underlying depression that may also be present. Depression and suicide ideation/attempts are also lifelong risks for PTSD patients. Depression patients often present with extreme sadness, emptiness, irritable mood, and somatic and cognitive changes (Chand et al., 2021). This diagnosis was refuted because the patient does not report any extreme sadness, and all symptoms reported are associated with PTSD.
4. Anxiety Disorders: Increased adverse emotional and physiological reactions in the patient could be mistaken for panic attacks or another specific anxiety illness. Fear is related to anxiety, which appears as a future-focused emotional state involving a sophisticated cognitive, affective, physiological, and behavioral response system geared at preparing for impending events or situations viewed as threatening (Chand & Marwaha, 2022). This diagnosis was refuted because the patient experiences fear from past warzone events rather than anticipated events (PTSD SOAP Note Example).

PTSD SOAP Note Example of PLAN:

SSRIs or SNRIs or trauma-focused psychotherapy or combining both can effectively treat PTSD.

Medication: Selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) are the first-line drugs recommended for the treatment of PTSD. Sertraline and paroxetine for treating PTSD symptoms (Mann & Marwaha, 2022). Clonidine and prazosin for decreasing trauma-related nightmares. Trazodone for treating insomnia. Risperidone to enhance the standard antidepressant regimen.

Talk Therapy (Psychotherapy):

Cognitive behavioral therapy (CBT): The patient is introduced to coping skills and self-calming techniques to ease physical symptoms (Carpenter et al., 2018). The patient also learns to recognize unrealistic thoughts and behaviors and replace them with appropriate ones.

Acceptance and commitment therapy (ACT): The patient will learn to be mindful of coping with unwanted thoughts and feelings (Sianturi et al., 2018).

Education:

• Maintain a consistent routine and schedule
• Anticipate stressful situations
• Practice stress management and self-calming techniques learned from the therapist

Contact the office if:

• The symptoms do not get better or get worse
• You identify signs of depression like change in weight, persistent sadness or irritable mood, avoiding family, loss of energy, and feelings of guilt or worthlessness.

Duration until next scheduled visit: 4 weeks

Reflection

The patient’s case is an example of the many incidences of PTSD among war veterans. Even though PTSD affects around eight million American adults yearly beyond the military, it is particularly severe for war veterans. Recent veterans not only have a higher chance of developing PTSD than people in the general population, but they also face unique challenges in getting proper care. These include the lengthy wait times at V.A. medical facilities, the social stigma associated with mental illness within military communities, and the need for them to receive either an honorable or general discharge to access Department of Veterans Affairs (V.A.) medical benefits. Less than half of returning veterans in need of mental health services receive any treatment, and of those receiving treatment for PTSD and major depression, less than one-third are receiving evidence-based care, according to a report by the RAND Center for Military Health Policy Research.

The patient in this case study shows the existence of war-induced psychological Trauma. The flashbacks of the war zone events and the response to war-like events are detrimental to the patient’s quality of life. The symptoms are more likely to affect his relationship with his fiancé and family if not addressed adequately. Talk therapy is the first-line treatment approach for PTSD. It involves patients disclosing their experiences to the psychiatrist to make sense of their Trauma and begin recovery from their current mental status. Importantly, involving family, including the patient’s fiance, parents, and siblings, is fundamental to a quick recovery. Family is a support system for the patient, making him feel safe, loved, and cared for. Understanding the family history is crucial to developing a comprehensive treatment plan. In this case study, the patient’s grandfather is also a veteran and developed depression due to the war experience. Mental illnesses can be linked to family history, and understanding the history allows for proper diagnosis and the development of appropriate interventions, as highlighted in the above treatment plan (PTSD SOAP Note Example).

Conclusion

The patient presents with many symptoms that are indicative of PTSD. PTSD, anxiety disorders, depression, and acute stress syndrome can have overlapping signs and symptoms, and a comprehensive assessment is required to come up with the correct diagnosis. Most veterans experience PTSD due to war-related traumatic events. (PTSD SOAP Note Example). Depression is common among war veterans, using the patient’s grandfather as an example. Treating PTSD is complex and requires a complete understanding of the patient’s personality and situational explanations coupled with pharmacological and non-pharmacological interventions.

References

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta‐analysis of randomized placebo‐controlled trials. Depression and anxiety, 35(6), 502-514.

Chand, S. P., & Marwaha, R. (2022). Anxiety. StatPearls [Internet].

Chand, S. P., Arif, H., & Kutlenios, R. M. (2021). Depression (Nursing).

Fanai, M., & Khan, M. A. (2020). Acute stress disorder.

Mann, S. K., & Marwaha, R. (2022, February 7). Posttraumatic stress disorder. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK559129/

Sianturi, R., Keliat, B. A., & Wardani, I. Y. (2018). The effectiveness of acceptance and commitment therapy on anxiety in clients with stroke. Enfermeria Clinica, 28, 94-97.

“Fear,” according to the DSM-5-TR, “is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat” (APA, 2022). All anxiety disorders contain some degree of fear or anxiety symptoms (often in combination with avoidant behaviors), although their causes and severity differ. Trauma-related disorders may also, but not necessarily, contain fear and anxiety symptoms, but their primary distinguishing criterion is exposure to a traumatic event. Trauma can occur at any point in life. It might not surprise you to discover that traumatic events are likely to have a greater effect on children than on adults. Early-life traumatic experiences, such as childhood sexual abuse, may influence the physiology of the developing brain. Later in life, there is a chronic hyperarousal of the stress response, making the individual vulnerable to further stress and stress-related disease.

Photo Credit: Hill Street Studios / Blend Images / Getty Images

For this Assignment, you practice assessing and diagnosing patients with anxiety disorders, PTSD, and OCD. Review the DSM-5-TR criteria for the disorders within these classifications before you get started, as you will be asked to justify your differential diagnosis with DSM-5-TR criteria.