Unit 9 Clinical SOAP Note on PTSD

Unit 9-Clinical SOAP Note on PTSD.900w. 4 references. Due 7-5-24

Instructions

Each week students will choose one patient encounter to submit a Follow-up SOAP note for review.  This week’s topic is PTSD.

Follow the rubric to develop your SOAP notes for this term.

The focus is on your ability to integrate your subjective and objective information gathering into formulation of diagnoses and development of patient-centered, evidence-based plans of care for patients of all ages with multiple, complex mental health conditions. At the end of this term, your SOAP notes will have demonstrated your knowledge of evidence-based practice, clinical expertise, and patient/family preferences as expected for an independent nurse practitioner incorporating psychotherapy into practice.

 

 

 

Resource to use

Course Description

This course prepares students to assess, diagnose, and manage mental health care needs across the lifespan. Emphasis will be placed on underlying acute and chronic psychiatric/mental health diagnoses. Clinical opportunities will be utilized for all PMHNP to apply concepts in primary and acute care settings with adults and families.

Program: Graduate Nursing

Resources

Carlat, D. J. (2023). The psychiatric interview (4th ed.). Philadelphia, PA: Wolters Kluwer. ISBN: 9781975212971

American Nurses Association & American Psychiatric Nurse Association. (2015).  Psychiatric–mental health nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: American Nurses Credentialing. ISBN-13: 978-1558105553 ISBN-10: 1558105557

American Psychiatric Association. (2022).  Diagnostic and Statistical Manual of Mental Disorders, Text Revision Dsm-5-tr (5th ed.) (DSM-5). Washington DC: APA Press. ISBN: 978-0890425763

Johnson, K., & Vanderhoef, D. (2016).  Psychiatric mental health nurse practitioner review manual (4th ed.). Silver Spring, MD: American Nurses Association. ISBN: 978-1-935213-79-6

Robert Joseph Boland, Verduin, M. L., Ruiz, P., Arya Shah, & Sadock, B. J. (2021).  Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Philadelphia, PA: Lippincott Williams, and Wilkins. 9781975145569

Recommended

Bickley, L. (2016).  Bates’ Guide to Physical Examination and History-Taking [VitalSouce bookshelf version]. https://batesvisualguide.com/. Eleventh, North American Edition; Lippincott Williams & Wilkins: ISBN 1609137620

Corey, G. (2016).  Theory and practice of counseling and psychotherapy (10th ed.). Boston, MA:Cengage. ISBN: 9781305263727

Heldt, J. P., MD. (2017).  Memorable psychopharmacology. Create Space Independent Publishing Platform. ISBN-13: 978-1-535-28034-1

Shea, S. C. (2017).  Psychiatric interviewing: The art of understanding (3rd ed.) Elsevier.

Stahl, S. M. (2013).  Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press. ISBN 978-1-107-68646-5

Stahl, S. M. (2020).  Prescriber’s guide: Stahl’s essential psychopharmacology (7th ed.). Cambridge University Press. ISBN 978-1108926010

 

 

 

 

 

Sample

 

Unit 5 SOAP Notes bipolar

SOAP Note

Subjective:

Chief complaint (in patient’s own words): “I’ve been feeling really up and down lately. One minute I’m on top of the world and can’t stop moving and talking, and the next I’m crashing hard and just want to stay in bed all day.”

History of present illness: The patient is a 28-year-old female who presents with worsening symptoms of bipolar disorder over the past 2-3 weeks. She reports experiencing periods of elevated mood, increased energy, racing thoughts, pressured speech, and a decreased need for sleep alternating with periods of depressed mood, fatigue, lack of motivation, and social withdrawal. During the manic phases, she describes feeling “like I’m on fire and can conquer the world.” She has exhibited impulsive behaviors such as excessive spending and hyper-sexuality. She states, “I went on a huge shopping spree and maxed out three credit cards buying unnecessary things.” She has also experienced periods of irritability and has had conflicts with family members during these episodes. The depressive episodes are characterized by persistent low mood, anhedonia, poor concentration, feelings of worthlessness, and thoughts of “not wanting to go on.” She reports difficulties getting out of bed and a lack of self-care during these times

Current Medications: Lithium 600 mg daily, Aripiprazole 10 mg daily

Allergies: No known drug allergies

Past Medical History: Unremarkable

Past Psychiatric History: Diagnosed with Bipolar I Disorder at age 22 after first manic episode with psychotic features requiring hospitalization. Multiple subsequent episodes over the years.

Family History: Mother has a history of major depressive disorder.

Relevant personal and social history: The patient is currently unmarried and lives alone in an apartment. She has a close relationship with her parents, who provide support, but strained relationships with some other family members due to the erratic nature of her illness. She works part-time as a graphic designer but has struggled to maintain consistent employment during acute episodes. She denies any history of substance abuse or legal issues. No recent significant psychosocial stressors were identified.

Objective:

 

Vitals: BP 132/88, HR 98, RR 16, Temp 98.6°F

ROS: Positive for sleep disturbance, poor concentration, pressured speech as described above. Otherwise negative.

Mental Status Exam:

· Appearance – Disheveled, overly groomed with excessive makeup

· Behavior – Hyperactive, fidgety, easily distracted

· Speech – Loud, pressured, rapid rate

· Mood – Euphoric

· Affect – Mood-congruent, labile, broad range

· Thought Process – Flight of ideas, tangential Thought Content – No overt delusions or paranoia

· Perceptions – Denies hallucinations

· Cognition – Intact attention and concentration, recent/remote memory intact

· Insight – Fair, minimizes symptoms at times

· Judgment – Fair Other – Psychomotor agitation

Psychiatric Screening Measures: PHQ-9 – 6 (Minimal depression) MDQ – Positive screen for bipolar disorder

Psychiatric Screening Measures: PHQ-9 – 6 (Minimal depression) MDQ – Positive screen for bipolar disorder (Roberts, L. W. (Ed.). (2019).

Assessment:

Diagnosis: Bipolar I Disorder, Current Episode Manic, Severe (F31.2)

DSM-5 Criteria Met:

· Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy

· Mood disturbance sufficient to cause marked impairment in social/occupational functioning

· At least 3 of the following (4 if mood is only irritable): grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, excessive involvement in pleasurable activities with potential for painful consequences

· Not attributable to physiological effects of a substance or other medical condition (American Psychiatric Association. (2013).

Potential Obstacles to Treatment:

· Medication non-adherence

· Lack of consistent social support system

· Vocational and financial instability

· Potential for insight to worsen during acute manic episodes

· Stigma associated with mental illness

Plan:

• Adjust medication regimen:

• Increase lithium dose to 900 mg daily (obtain lithium level after 5 days)

• Increase aripiprazole to 20 mg daily

• Add lorazepam 1-2 mg every 6 hours as needed for agitation/insomnia (Roberts, L. W. (Ed.). (2019).

• Refer to partial hospitalization program for intensive therapy, psychoeducation on bipolar disorder, and medication management. Coordinate family involvement.

• Psychotherapy:

• Individual therapy focused on cognitive behavioral strategies, coping skills, trigger identification

• Family therapy to increase support system’s understanding of the illness

• Encourage maintaining regular sleep/wake cycle, limiting potential triggers (caffeine, stress), and engaging in relaxation techniques like mindfulness.

• Consider involvement of case manager or community resources to assist with adherence and functional support during acute episodes. (McIntyre et al., 2020)

• Follow up appointment in 2 weeks:

• Assess response to medication changes and need for further adjustments

• Evaluate for presence of depressive or psychotic symptoms

• Review any labs (lithium level, metabolic monitoring)

• Coordinate step-down level of care if stabilized (Roberts, L. W. (Ed.). (2019).

 

 

 

 

 

 

 

References

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., … & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841-1856. https://doi.org/10.1016/S0140-6736(20)31544-0

Roberts, L. W. (Ed.). (2019). The American Psychiatric Association publishing textbook of psychiatry. American Psychiatric Pub.

 

 

 

 

 

 

 

**Unit 9 Clinical SOAP Note on PTSD**

**Subjective:**
– **Chief Complaint:** The patient, a 35-year-old male veteran, reports recurring nightmares, intrusive memories, and heightened anxiety since returning from active duty six months ago. He describes feeling constantly on edge, avoiding crowds, and experiencing flashbacks of combat situations.

**History of Present Illness:**
– The patient presents with symptoms consistent with Post-Traumatic Stress Disorder (PTSD) following multiple deployments in combat zones. He describes experiencing intense fear, helplessness, and horror during traumatic events, leading to persistent re-experiencing of the trauma through memories, nightmares, and flashbacks. His symptoms have significantly impaired his ability to function socially, occupationally, and interpersonally.

**Current Medications:** None

**Allergies:** No known drug allergies

**Past Medical History:** No significant medical history reported

**Past Psychiatric History:** No previous psychiatric diagnoses

**Family History:** No significant psychiatric history in the family

**Relevant Personal and Social History:** The patient is married with two young children. He served in combat roles for 10 years and was honorably discharged. He reports difficulty adjusting to civilian life, including challenges with sleep, anger management, and irritability.

**Objective:**
– **Vitals:** BP 130/80, HR 88, RR 18, Temp 98.4°F
– **Physical Examination:** Within normal limits
– **Mental Status Exam:**
– **Appearance:** Tense, hypervigilant
– **Behavior:** Avoidant of eye contact, startled by sudden noises
– **Speech:** Normal rate and volume
– **Mood:** Anxious
– **Affect:** Restricted
– **Thought Process:** Linear
– **Thought Content:** Preoccupied with traumatic memories
– **Perceptions:** No hallucinations or delusions
– **Cognition:** Oriented ×3, intact memory and concentration
– **Insight/Judgment:** Fair

**Psychiatric Screening Measures:**
– PTSD Checklist for DSM-5 (PCL-5): Score of 65, indicating severe PTSD symptoms

**Assessment:**
– **Diagnosis:** Post-Traumatic Stress Disorder (PTSD) (F43.10)
– **DSM-5 Criteria Met:**
– Exposure to actual or threatened death, serious injury, or sexual violence
– Presence of intrusive symptoms (e.g., nightmares, flashbacks)
– Persistent avoidance of trauma-related stimuli
– Negative alterations in cognition and mood
– Alterations in arousal and reactivity
– **Potential Obstacles to Treatment:**
– High risk of suicide due to severe symptoms and history of combat trauma
– Social isolation and avoidance behaviors hindering therapy engagement
– Limited support network outside immediate family

**Plan:**
– **Pharmacological Treatment:**
– Initiate sertraline 50 mg daily, titrated up to 100 mg daily over two weeks to target symptoms of anxiety and depression associated with PTSD
– Consider prazosin 1 mg nightly for nightmares if symptoms persist after two weeks
– Monitor for adverse effects and therapeutic response

– **Non-Pharmacological Treatment:**
– Begin cognitive behavioral therapy (CBT) focused on trauma processing, exposure therapy, and stress management techniques
– Involve family members in therapy sessions to enhance support and understanding
– Refer to Veteran Affairs (VA) support groups and community resources for additional psychosocial support

– **Patient Education:**
– Educate patient and family on PTSD symptoms, triggers, and coping strategies
– Provide information on medication adherence and potential side effects
– Discuss the importance of maintaining regular follow-up appointments

– **Referral:**
– Refer to VA PTSD clinic for specialized treatment programs and comprehensive care

– **Follow-Up:**
– Schedule follow-up appointment in two weeks to assess treatment response, adjust medications if necessary, and evaluate for safety concerns

**References:**
– American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
– Roberts, L. W. (Ed.). (2019). The American Psychiatric Association publishing textbook of psychiatry. American Psychiatric Pub.
– Veterans Affairs. (2020). PTSD: National Center for PTSD. Retrieved from https://www.ptsd.va.gov/
– National Institute of Mental Health. (2022). Post-traumatic stress disorder. Retrieved from https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd

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