Anxiety and PTSD Soap Note

year old female KD,was refer by the drug and rehab counselor.for severe Anxiety and depression,she is out of work,inability to concentrate,relapse on Alcohol after 100 days drug free,divorce d in 2007(SOAP Note on Anxiety and PTSD Comprehensive Essay Example),she is IRish,heterosexual ,NKA,5’,120 lbs,history of breast CA,after Covid she had the surgery,she find it very hard to concentrate,read,she has to read things over Andover in other in other to retain,raised by a divorced parents at 4 years,dad died at 50 years,of a heart problem ,cousin jump in front of a train kill himself.she was put on Buspirone 20 mg ,Bupropione 415 mg daily,Gabapentin 300 mg for pain and anxiety,father had PTSD,Mother had Anxiety,grand ma Depression,she had a bad break up with her significant other.her son was not with her ,working 65 hrs a week,history of sexual abused at 10 year old,physical abused by step father,and father.verbal abused,stop taking drug 2 years ago.smoked vaped,alcohol,financial problem,make her relapsed,she does not have a primary MD.she had a bad car accident 19995,was at university hospital,when she has anxiety she sweat a lot she can not move,she scared,when she is in therapy she can not talk about it,she start crying,she felt worthless,a failure,a bad mother.she has a trust problem,patient needs Dialeptical behavior therapy. (SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

SOAP Note on Anxiety and PTSD Comprehensive Essay Example

Subjective:

CC (chief complaint): Severe anxiety and depression

HPI: The patient, a 45-year-old Irish female, was referred for counseling by the drug and rehab counselor for severe anxiety and depression. She reports an inability to concentrate and a recent relapse into alcohol after being drug-free for 100 days. The patient reports a history of sexual abuse at age ten and physical and verbal abuse by her father and stepfather. She also reports a family history of PTSD, anxiety, and depression. The patient had breast cancer and had surgery after COVID. She finds it very hard to concentrate and read, and she has to read things repeatedly to retain them. She has a trust problem and a bad break-up with her significant other. The patient reports financial problems, which make her relapse. She smoked, vaped, and drank alcohol. She does not have a primary MD. The patient had a bad car accident in 1995 and was at the university hospital. When she has anxiety, she sweats a lot and cannot move. She is scared and cannot talk about it in therapy. She starts crying and feels worthless, a failure, and a bad mother.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

Past Psychiatric History:

• General Statement: The patient entered treatment in 1995 following a bad car accident.
• Caregivers (if applicable): None reported.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)
• Hospitalizations: The patient was hospitalized at the university after a car accident in 1995.
• Medication trials: She tried Buspirone 20mg, Bupropion 415mg daily, and Gabapentin 300mg for pain and anxiety. She stopped taking the drugs two years ago.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)
• Psychotherapy or Previous Psychiatric Diagnosis: None reported.

Substance Current Use and History: The patient reports a history of smoking, vaping, and alcohol use. She recently relapsed on alcohol after being drug-free for 100 days.

Family Psychiatric/Substance Use History: The patient reports a family history of PTSD, anxiety, and depression. Her father had PTSD, her mother had anxiety, and her grandmother had depression. Her cousin jumped in front of a train and killed himself.

Psychosocial History: The patient was raised by divorced parents at four years old. Her father died at 50 years of a heart problem. She was divorced in 2007. She had a bad break-up with her significant other, and her son is not with her and previously worked 65 hours a week. She is currently out of work and reports financial problems, which make her relapse.

Medical History: The patient had breast cancer and had surgery after COVID.

Current Medications: No current medication.

Allergies: NKA

Reproductive Hx: Heterosexual

ROS

• GENERAL: The client reports no weight loss, fever, or chills. Denies weakness or fatigue.
• HEENT: The head is normocephalic and atraumatic. No changes in vision or hearing. No nasal congestion and the oropharynx is clear.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)
• SKIN: The skin is intact with no lesions or rashes.
• CARDIOVASCULAR: Regular heart sounds, no murmurs or gallops.
• RESPIRATORY: No wheezing, rales, or rhonchi.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)
• GASTROINTESTINAL: Soft, non-tender, and non-distended abdomen. Normoactive bowel sounds.
• NEUROLOGICAL: No tremors or abnormal movements.
• MUSCULOSKELETAL: No deformities or joint swelling. The range of motion is full.
• HEMATOLOGIC: No bruising, bleeding, or anemia.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)
• LYMPHATICS: No history of splenectomy or lymphadenopathy
• ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

Objective

Physical exam: NA

Vital Signs: T- 98.7 R 15 P 87 BP 119/79, H 5’, W 120lbs, BMI 23.4 (Normal BMI)

Diagnostic results: Diagnostic studies may include a complete blood count, liver function tests, and a urine toxicology screen to rule out substance-induced anxiety and depression.

Assessment:

Mental Status Examination: The patient is a 44-year-old Irish female who appears her stated age. The patient is alert and oriented to person, place, and time. She is cooperative but appears anxious and distressed. The patient appears anxious and distressed. Her speech is coherent and relevant. Her mood is depressed, and her affect is constricted. She denies delusions or hallucinations. Her cognition is intact, but she reports difficulty concentrating and retaining information. She has a history of trauma and a family history of mental illness. Denies suicide or homicide ideation. No risk of self-harm or harm to others is appreciated.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

Differential Diagnoses:

1. 309.81 (F43.10), Posttraumatic Stress Disorder (PTSD): The DSM-5 criteria for PTSD diagnosis includes actual or perceived exposure to a traumatic event, invasive and distressing memories or dreams of the event, avoidance of reminders of the event, negative changes in mood and cognition, intrusive symptoms such as flashbacks, persistent avoidance of marked psychological distress, and increased arousal and reactivity (American Psychiatric Association [APA], 2019).
2. 300.02 (F41.1), Generalized Anxiety Disorder (GAD): The diagnostic criteria for GA are excessive and uncontrollable worry, difficulty concentrating, restlessness, muscle tension, sleeplessness, fatigue, and irritability (APA, 2019).(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)
3. Moderate (p. 188), 296.32 (F33.1 Major Depressive Disorder (MDD): The DSM-5 diagnostic criteria for MDD include the presence of depressed mood, loss of interest or pleasure, feelings of worthlessness, concentration inability, and recurring thoughts of death or suicide ideation (APA, 2019).(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

Reflections:

Based on the subjective and objective data, the client has a history of trauma, physical and verbal abuse, and a recent major surgery which may have contributed to her current mental health symptoms. Besides, the client has a history of a bad accident and being unable to stay with her son. These experiences and symptoms suggest PTSD as the primary diagnosis. The patient presents with symptoms of severe anxiety and depression, including an inability to concentrate, difficulty with memory, and a relapse into alcohol use after being drug-free for 100 days. She has a history of substance abuse and has experienced a recent bad break-up, financial problems, and a car accident which may have exacerbated her symptoms.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

Furthermore, the patient’s anxiety appears chronic and unrelated to any situation or object. Sometimes the anxiety leads to physical symptoms such as sweating and trembling (Boland & Verduin, 2021). The patient’s symptoms have persisted significantly and are affecting her daily functioning. These experiences also suggest GAD and MDD. However, the patient history and consequent drug abuse and symptoms are better explained by PTSD as the primary diagnosis. Therefore, there is a need for a more in-depth assessment and gathering additional information to make a more accurate diagnosis.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

Important lessons from this case include the importance of taking a comprehensive approach to mental health assessment and treatment, especially when there is a history of trauma and abuse (Sadock et al., 2015). I also learned that a patient’s social determinants of health, such as their cultural background, socioeconomic status, and ethnicity, can significantly impact their mental health and well-being.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

The legal/ethical considerations essential in this case include informed consent, confidentiality, and potential harm to self or others. Providing informed consent and upholding confidentiality is vital in establishing appropriate PMHNP-client relationships, which is vital for achieving positive health outcomes (Bipeta, 2019). In addition, ensuring that the patient receives culturally competent care and their rights and dignity are respected is important. This will enhance their involvement in the psychiatric evaluation and treatment plan.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

Case Formulation and Treatment Plan 

1. Pharmacotherapy: Start Sertraline 25mg daily for PTSD. Sertraline effectively treats PTSD symptoms, including psychological symptoms, anger, and other related symptoms (Kline et al., 2020).(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)
2. Psychotherapy: Refer for Dialectical Behavioural Therapy (DBT) to address her trust issues and other PTSD symptoms. Bohus et al. (2020) established that DBT is effective in managing PTSD symptoms among women with a history of childhood abuse.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)
3. Education: Educate the patient on the impact of substance abuse on her health. Provide the client with information on local alcohol anonymous groups and community health resources. Educate the client on the importance of self-care, including regular exercise, healthy eating, and good sleep hygiene.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

RCT: 4 weeks

Follow-up: Consequent visits after four weeks to monitor the client’s progress and reevaluate the treatment plan based on the client’s response to intervention.

References

American Psychiatric Association. (2019). Diagnostic and statistical manual of mental disorders (7^th ed.). American Psychiatric Publishing, Inc.   

Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of psychological medicine, 41(2), 108-112. https://doi.org/10.4103%2FIJPSYM.IJPSYM_59_19

Boland, R., & Verduin, M. (2021). Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry. Lippincott Williams & Wilkins.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Bohus, M., Kleindienst, N., Hahn, C., Müller-Engelmann, M., Ludäscher, P., Steil, R., … & Priebe, K. (2020). Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) compared with cognitive processing therapy (CPT) in complex presentations of PTSD in women survivors of childhood abuse: a randomized clinical trial. JAMA Psychiatry, 77(12), 1235-1245. https://doi.org/10.1001/jamapsychiatry.2020.2148

Kline, A. C., Feeny, N. C., & Zoellner, L. A. (2020). Race and cultural factors in an RCT of prolonged exposure and sertraline for PTSD. Behavior Research and Therapy, 132, 103690. https://doi.org/10.1016/j.brat.2020.103690

Frequently Asked Questions

How do you explain PTSD and anxiety?

PTSD (Post-Traumatic Stress Disorder) is a mental health condition that can develop after a person experiences a traumatic event, such as a life-threatening incident, violence, or natural disaster. It often leads to symptoms like flashbacks, nightmares, hypervigilance, and emotional numbness, disrupting daily life.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

Anxiety is a general term for excessive worry, fear, or apprehension about future events or situations. It can manifest as physical symptoms like rapid heart rate, sweating, and restlessness. Anxiety disorders encompass a range of conditions, including generalized anxiety disorder, panic disorder, and social anxiety disorder, each characterized by specific patterns of distress and impairment.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

Can you have PTSD and anxiety?

Yes, it is possible to have both Post-Traumatic Stress Disorder (PTSD) and anxiety. PTSD is a specific mental health condition that can include symptoms of anxiety, such as intense worry, fear, and restlessness. However, while anxiety can be a component of PTSD, having both conditions simultaneously is not uncommon and may require comprehensive treatment approaches.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

How do you write SOAP notes for mental health?

SOAP notes for mental health follow a structured format. S (Subjective): Document the client’s self-reported experiences, emotions, and concerns. O (Objective): Record the clinician’s observations, assessments, and any measurable data. A (Assessment): Analyze the client’s progress, diagnoses, and formulation of treatment plans. P (Plan): Outline the therapeutic interventions, goals, and next steps, including medications or referrals.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)

What are coping skills for PTSD symptoms?

Coping skills for PTSD symptoms often include grounding techniques, such as deep breathing and mindfulness, to manage distressing emotions and stay present. Engaging in regular physical activity and maintaining a structured routine can help regulate mood and reduce anxiety. Seeking support through therapy, counseling, or support groups provides a safe space to process trauma and develop effective coping strategies.(SOAP Note on Anxiety and PTSD Comprehensive Essay Example)