SOAP Note

Patient Demographic Information:  J.B., 65 years old, Caucasian male, married, retired. Former supervisor in the prison system for 20 years. Date of visit: 11/01/2025

Subjective

Chief Complaint: “I feel anxious all the time, and I can’t stand noises. I don’t enjoy anything anymore”: SOAP Note.

HPI:  J.B., a 65-year-old retired prison supervisor, presents with symptoms suggestive of post-traumatic stress disorder (PTSD) that began about five years ago. He attributes his symptoms to his experiences working in the prison system, where he witnessed suicides, attempted suicides, overdoses, and acts of violence. He reports heightened anxiety triggered by noises, especially repetitive sounds, which remind him of specific traumatic incidents. He consciously avoids crowded places, people, and certain media types, such as television or radio.

He struggles with post-traumatic stress disorder symptoms, including recurrent flashbacks of the incidents he encountered, especially suicides. However, he has no problem falling asleep or suffering nightmares, and yet he wakes up exhausted each morning. He reports no suicidal ideation (SI) or homicidal ideation (HI); however, post-surgery following an accident, the patient admits to feeling low at times.

Past Psychiatric History:  The patient has no prior medical account of psychiatric disorders or hospitalization.

Review of Systems: 

• General: Persistent fatigue.
• Neurological: No complaints of dizziness or headaches.
• Psychiatric: Anxiety, anhedonia, flashbacks. No SI/HI.
• Other Systems: Denies issues related to other systems.

Current Medication List: He is currently on Lisinopril 10 mg daily for hypertension.

Allergies: There are no known drug allergies (NKDA).

Objective Information: 

Vital Signs: Not mentioned

Physical examination: There were no visible physical anomalies. The patient seems well and not in any immediate pain.

MSE:

• Appearance: Well-groomed and clean-dressed.
• Behavior: Cooperative but mildly avoidant.
• Speech: Fluent, coherent, and interactive. No stuttering or escaping words.
• Mood:
• Affect: Blunted, minimal emotional display.
• Thought Process: Coherent and relevant.
• Thought Content: Preoccupations but no odd or culturally incongruent ideas. No suicidal or homicidal ideation. Flashbacks related to traumatic events were noted.
• Perceptual Disturbances: None reported.
• Cognition: Preserved; oriented to time, place, and person.
• Insight: Satisfactory, with an understanding of the current situation.
• Judgment: Sound, capable of making reasoned choices concerning treatment.

Assessment

Diagnoses

1. Post-Traumatic Stress Disorder (PTSD) (ICD-10: F43.10):

It is crucial to diagnose PTSD by assessing J.B.’s trauma exposure history within his 20 years of experience as a prison supervisor. He presented persistent modifiers of PTSD, including auditory intrusion and deafening sounds that remind him of tragic incidents like suicides he encountered in the prison system. Inavoidant behaviors were observed from his refusal to sit in areas with noise or public, as well as his inability to interact with media due to increased anxiety.

He employs emotional numbing through the loss of interest in hobbies, uses emotional output, and has hyperarousal, marked by sensitivity to sound and alertness. These symptoms correspond with the DSM-5-TR criteria of exposure to trauma, symptoms related to re-experiencing, avoidance, changes in mood and negativity, and hyperarousal.

Rationale

The duration of these symptoms, their relationship with trauma reminders, and their interference with the individual’s ability to function provide support for PTSD. Such symptoms include fatigue and anhedonia, which makes getting a dual diagnosis important, as Mann and Marwaha (2022) suggested.

2. Major Depressive Disorder (MDD), Persistent (ICD-10: F33.1):

J.B.’s inability to feel pleasure, referral fatigue, and lack of interest in activities for up to five years make him a client suffering from persistent depressive disorder, according to DSM-5-TR. He said he usually feels fatigued during the day but was recently sleeping well, symptoms which suggest he is experiencing sub-optimal restorative rest and symptoms of depression. The patient shared that he no longer wants to engage in activities he used to do for recreation or pleasure, including hobbies and social events, hence his lack of motivation and energy.

Despite his denial of sadness or low mood, acute or chronic, the appellant’s evidence of being emotionally detached and apathetic portrays a picture of chronic depressive disorders. The overlap between emotional numbing in PTSD and symptoms of MDD further complicates the clinical picture but supports the dual diagnosis.

Rationale

The prolonged duration and pervasive nature of depressive symptoms, coupled with their detrimental effect on daily functioning, justify an MDD diagnosis. Comorbid MDD can intensify PTSD-related emotional and functional impairments, highlighting the importance of an integrated treatment plan (Bains & Abdijadid, 2023).

Differential Diagnoses

1. Generalized Anxiety Disorder (GAD) (ICD-10: F41.1):

GAD is defined as an ongoing and extreme level of anxiety and worry that spans across the different aspects of life coupled with physical symptoms such as agitation and difficulty concentrating. Indeed, J.B. does appear anxious, but it is because of traumatizing cues rather than mere ruminative worrying. His heightened sensitivity to noises, flashbacks, and avoidance behaviors are distinctly linked to his traumatic experiences in the prison system, which is inconsistent with GAD.

Rationale

GAD is ruled out because J.B.’s anxiety is episodic and situational, clearly associated with trauma triggers rather than the uncontrollable, widespread worry characteristic of GAD. This distinction supports a PTSD diagnosis, which requires trauma-focused treatment strategies (Munir & Takov, 2022).

2. Adjustment Disorder with Anxiety (ICD-10: F43.22):

Adjustment Disorder with Anxiety involves symptoms triggered by a stressor, typically resolving within six months after the stressor ends, as noted by Geer (2023). J.B.’s symptoms have persisted for over five years, exceeding the temporal criteria for this diagnosis. His flashbacks, hyperarousal, and emotional numbing also indicate greater severity than what is seen in adjustment disorders.

Rationale

The chronic and debilitating nature of J.B.’s symptoms exclude Adjustment Disorder with Anxiety. His presentation aligns more with PTSD, requiring trauma-specific care rather than the short-term interventions used for adjustment disorders (Geer, 2023).

Plan

Pharmacological Treatment: Sertraline 50 mg PO daily, a selective serotonin reuptake inhibitor (SSRI), is prescribed. According to Singh and Saadabadi (2021), Sertraline is FDA-approved for PTSD and is supported by evidence for its efficacy in reducing symptoms such as intrusive thoughts, emotional numbing, and hyperarousal (Stein et al., 2021).

Non-Pharmacological Treatment: J.B. will undergo Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), the gold standard for PTSD treatment. TF-CBT effectively targets trauma-related intrusive thoughts and avoidance behaviors, aiding emotional and functional recovery, as indicated by Ennis et al. (2021). Additionally, sleep hygiene counseling will be provided to address J.B.’s persistent fatigue and improve restorative sleep patterns.

Education: According to Mann and Marwaha (2022), education will focus on explaining PTSD and its interaction with depressive symptoms to J.B. and his family. The importance of medication adherence and attending follow-up appointments will be emphasized. Handouts with coping strategies for PTSD triggers and information on community support resources will be shared to enhance long-term management and provide comprehensive support.

References

Bains, N., & Abdijadid, S. (2023). Major depressive disorder. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559078/

Ennis, N., Sijercic, I., & Monson, C. M. (2021). Trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder under ongoing threat: A systematic review. Clinical Psychology Review, 88(1), 102049. https://doi.org/10.1016/j.cpr.2021.102049

Geer, K. (2023). Adjustment disorder. Primary Care: Clinics in Office Practice, 50(1), 83–88. https://doi.org/10.1016/j.pop.2022.10.006

Mann, S. K., & Marwaha, R. (2022). Posttraumatic stress disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/32644555/

Munir, S., & Takov, V. (2022, October 17). Generalized anxiety disorder. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28722900/

Singh, H. K., & Saadabadi, A. (2021). Sertraline. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/31613469/

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Using the SOAP Note Template provided write a complete note on this patient who has a history of trauma.

B is a 65-year-old Caucasian male, retired, married complaints of issues with PTSD. He worked as a supervisor in the prison system for 20 years. He retired within the last two years due to health concerns. He first began noticing issues with his anxiety and mood about 5 years ago.

He witnessed several suicides, attempted suicide, overdoses and violence in while working in the prison system. He states that many noises seem to bother him, increasing his anxiety levels. He is avoidant of public areas or areas with a lot of noise. He cannot even watch TV or listen to the radio without feeling on edge from nose.

He states that repetitive noises remind him of an inmate that would repetitively bang on her bed frame and startle the staff. He states that he does not necessarily feel like his mood is low most of the time, but that he just doesn’t care about anything anymore. No longer enjoys his hobbies or leaving his house. He feels tired all the time regardless of how much sleep he gets. He has flashbacks frequently, often when exposed to something that will trigger them.

Most of the time he has a flashback to one the suicides he witnessed as he feels those affected him worst. He is able to fall asleep easily and feels like he rests well during the night, but still feels tired during the day. Denies any issues with nightmares. He denies SI or HI.

Past Psych history: No psych history or hospitalization

Past medical history: HTN

Past surgery: None

Allergies: No known allergies

Medications: Lisinopril

 

Criteria

Demographic Information

Chief Complaint

History of Present Illness

Past Psychiatric History

Review of Systems

Description of criterion

Medication List

Vital Signs

Physical Exam

Mental Status Exam

Diagnoses With Rational

Differential Diagnoses

Pharmacological treatment

Non-Pharmacological Treatment

Education

References