CLINICAL SOAP NOTE

Student Name

Institution Affiliation
 Patient Identification

The patient being interviewed is Mary, a sixth-grade pupil whose parents have brought her in

for evaluation. She is reported to have survived a fatal accident that led loss of lives of her ten

fellow pupils, and the incident has affected her life greatly. She is ten years old.

SUBJECTIVE

Patient Information: Mary, ten years old

CC: “Our daughter never sleeps at night. She experiences a lot of nightmares, and we are

afraid about her condition, which is worsening daily.”

From Mary, “Since the accident happened, I see ghosts of my best friends at night, and I can’t

sleep comfortably. I am so afraid.”

HPI: The patient was well until the last one year when she was involved in a grisly road

accident that led to the loss of the lives of her classmates, with many others sustaining

injuries, including herself. The accident involved their school bus and a lorry, a head-on

collision. Mary was occupying the front seat and therefore witnessed the collision between

the two vehicles. The accident scene was frightening as helpless dead bodies were lying

everywhere with blood spilled everywhere. All this Mary witnessed, and she says to have

cried severely after seeing five of her best friends dead. She says to have next found herself in

hospital after three days. Since her hospital discharge, her parents say their daughter has been

leading a very uncomfortable life. She does not sleep at night and spends most of her time in

deep thoughts. Most of the time, she is in fear, thinking that anything might take away her

life. She experiences constant disturbing nightmares of the accident scene, and at some point,

she even says ghosts of her friends appear in her dreams. She has been reluctant to travel to

school by bus, citing they might get involved in another accident and die. She avoids

situations, people, or events that may exacerbate her memories and make her remember the
incident. She is full of flashbacks of the accident. Consequently, her parents have been forced

to transfer her to a nearby school in their neighbourhood, where she walks for only 100

meters. Her concentration at school is very poor as she experiences frightening thoughts even

during the daytime and doesn’t listen in class. She has been recording very poor grades for

the past few months. She cites that she tries to avoid thoughts of the incident by trying to

keep playing with her friends, but it has not helped in any way. Her mood has changed, and

she experiences angry outbursts towards her parents, friends, and outside people. She has lost

her esteem and feels unloved. Sometimes her heart beats so hard. She says to be guilty

sometimes, thinking she would have tried to talk to the driver to be more careful to avoid the

accident. Her interest in her classwork and home activities has reduced greatly. She has been

treated for this condition for three months and is on Sertraline, but her symptoms keep

worsening.

Current Medications: Sertraline 10 mg OD

Medical History: Was admitted when involved in an accident one year ago, operated on. No

chronic illness.

Allergies: None

Substance Use: None

Psychiatric History: Posttraumatic stress disorder. No other psychiatric illness was diagnosed.

Family History: She is the only daughter of her parents. No chronic or familial illness in her

family. Her mother works as a librarian while her father is an accountant.

Review of Systems.

Constitutional Symptoms: No fever, night sweats, or weight loss. Has disturbed sleep

patterns.
CNS: constant headache. No blurred vision, convulsions, or loss of consciousness.

CVS: Has palpitations; however, no chest pain, easy fatiguability, or orthopnea.

RESP: No cough, shortness of breath, or dyspnea.

GIT: No loss of appetite, diarrhea, constipation.

Musculoskeletal: Joint pains.

OBJECTIVE

General Examination

A young school girl in good condition, good nutritional status, and alert. She is not in any

obvious pain or respiratory distress but looks anxious. She has no jaundice, pallor,

dehydration, edema, lymphadenopathy, or cyanosis. Her vitals are all stable and within

normal ranges except her heart rate.

HR: 102

RR: 18

BP: 96/77 mmHg

TEMP: 37

SPO2: 96%

BMI: 19.6

General Examination

HEENT: Head normocephalic with a healed surgical scar on the scalp. Normal vision,

hearing, nasal anatomy. No dysphagia, normal oral health.

Neck: No jugular venous distension or lymphadenopathy.

Abdomen: Normal, except for healed surgical scars.

Mental State Examination

Mary is appropriate for her age and well groomed. She maintained meaningful eye contact

throughout the interview process with appropriate facial expression, relaxed posture, and

calmness. Her speech was of low volume with a fluent tone. Her mood was depressed and

sad. She had no inappropriate movements, tremors, or fidgeting. Her affect was congruent

and restricted. She had a linear and logical thought process with no hallucinations but

nightmares. She was fully aware, vigilant, and conscious of her condition. Her judgment was

intact, with a positive motivation to adhere to treatment and therapy. Her memory was intact.

Labs

Toxicology screen: Negative

CBC, TFTs, blood glucose, malaria parasite.

DIAGNOSIS

DSM5 Diagnosis: with ICD-10 codes

Dx: Post-traumatic stress disorder (PTSD) (F43.10)

The Diagnostic and Statistical Manual of Mental Disorders (DSM 5) provides a criterion for

diagnosing all mental disorders (Foa et al., 2018). DSM 5 has divided PTSD into 5

symptoms: intrusion, avoidance of thoughts and behaviors, negative thought patterns and

mood, and modifications in arousal and reactivity (Franklin et al., 2018). Intrusions do with

everything related to traumatic events that occur in an individual, which include upsetting

memories of the event, disturbing dreams related to the event, constant flashbacks that the
event may happen again and increased heart rate when one remembers about the events

(Franklin et al., 2018). Avoidance involves resisting anything that may precipitate memories

of such events by staying away from people, situations, or places (Hyland et al., 2018).

Changes in thoughts and mood involve self-blame, losing interest in what one loves to do,

social detachment, and low self-esteem (Weathers et al., 2018). Changed arousal includes

poor concentration, irritability, and difficulty sleeping (Hyland et al., 2018). To diagnose

PTSD, the individual must have experienced a traumatic event and the listed symptoms but

have been demonstrated for longer than one month.

Additionally, these symptoms must negatively impact other aspects of an individual (Foa et

al., 2018). Mary was involved in a fatal road accident which forms her traumatic event. She

has had memories, dreams, flashbacks, and nightmares relating to the accident that led to the

loss of her classmates. She avoids instances that might exacerbate her memories of the event

by distancing from people, changing her school, and trying not to think. She blames herself,

has lost pleasure in activities, lacks sleep at night, and poor concentration affects her school

grades. Therefore, the Diagnosis of PTSD will be appropriate regarding Mary’s symptomatic

presentation.

TREATMENT

Pharmacotherapy

Continue Sertraline therapy.

Selective serotonin reuptake inhibitors (SSRIs) like Sertraline 25mg OD and paroxetine 20

mg OD have been approved by the FDA for treating PTSD. They regulate serotonin levels

responsible for mood and anxiety hence symptomatic management. Pharmacotherapy is

indicated after the patient has undergone psychotherapy sessions. The patient is educated on

the side effects, including fatigue, drowsiness, dizziness, and nausea.

Cognitive-behavioural therapy (CBT) is a problem-solving skill for many mental disorders

like PTSD, generalized anxiety, and depression (Ennis et al., 2020). Trauma-focused CBT

involves psychoeducation, trauma reconstruction, and skill-building, which help a patient

overcome frightening flashbacks, nightmares, and dreams (Ennis et al., 2020). By revisiting

the trauma narrative, Mary can transform her intrusive thoughts, negative cognitions, and

abusive conduct. Guidelines have demonstrated the effectiveness of CBT as a first-line

modality in PTSD management by helping abolish negative thoughts in patients (Ennis et al.,

2020). She will also be trained to participate in social activities to reduce negative thoughts.

In so doing, this therapy and antidepressant medication will help her recover from her

condition with time.

Ennis, N., Shorer, S., Shoval-Zuckerman, Y., Freedman, S., Monson, C. M., & Dekel, R.

(2020). Treating posttraumatic stress disorder across cultures: A systematic review of

cultural adaptations of trauma-focused cognitive behavioural therapies. Journal of

Clinical Psychology, 76(4), 587–611. https://doi.org/10.1002/jclp.22909

Foa, E. B., Asnaani, A., Zang, Y., Capaldi, S., & Yeh, R. (2018). Psychometrics of the Child

PTSD Symptom Scale for DSM-5 for trauma-exposed children and

adolescents. Journal of Clinical Child and Adolescent Psychology: The Official

Journal for the Society of Clinical Child and Adolescent Psychology, American

Psychological Association, Division 53, 47(1), 38–46.

https://doi.org/10.1080/15374416.2017.1350962

Franklin, C. L., Raines, A. M., Chambliss, J. L., Walton, J. L., & Maieritsch, K. P. (2018).

Examining various subthreshold definitions of PTSD using the Clinician-

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Hyland, P., Shevlin, M., Fyvie, C., & Karatzias, T. (2018). Posttraumatic stress disorder and

complex posttraumatic stress disorder in DSM-5 and ICD-11: Clinical and

behavioural correlates. Journal of Traumatic Stress, 31(2), 174–180.

https://doi.org/10.1002/jts.22272

Weathers, F. W., Bovin, M. J., Lee, D. J., Sloan, D. M., Schnurr, P. P., Kaloupek, D. G.,

Keane, T. M., & Marx, B. P. (2018). The Clinician-Administered PTSD Scale for

DSM-5 (CAPS-5): Development and initial psychometric evaluation in military

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Zuromski, K. L., Ustun, B., Hwang, I., Keane, T. M., Marx, B. P., Stein, M. B., Ursano, R. J.,

& Kessler, R. C. (2019). Developing an optimal short-form of the PTSD Checklist for

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