Focused SOAP Note: Sherman Tremaine

• Review the Focused SOAP Note template, which you will use to complete this Assignment. There is also a Focused SOAP Note Exemplar provided as a guide for Assignment expectations.
• Review the video, Case Study: Sherman Tremaine (Transcript:  https://samples.eduwriter.ai/153232501/sherman-tremaine-a-case-study-in-mental.)
• You will use this case as the basis of this Assignment. In this video, a Walden faculty member is assessing a mock patient. The patient will be represented onscreen as an avatar.
• Consider what history would be necessary to collect from this patient.
• Consider what interview questions you would need to ask this patient.

Develop a focused SOAP note, including your differential diagnosis and critical-thinking process to formulate a primary diagnosis. Incorporate the following into your responses in the template:

• Subjective: What details did the patient provide regarding their chief complaint and symptomology to derive your differential diagnosis? What is the duration and severity of their symptoms? How are their symptoms impacting their functioning in life?
• Objective: What observations did you make during the psychiatric assessment?
• Assessment: Discuss the patient’s mental status examination results. What were your differential diagnoses? Provide a minimum of three possible diagnoses with supporting evidence, and list them in order from highest priority to lowest priority. Compare the DSM-5-TR diagnostic criteria for each differential diagnosis and explain what DSM-5-TR  criteria rules out the differential diagnosis to find an accurate diagnosis. Explain the critical-thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.
• Plan: What is your plan for psychotherapy? What is your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. Also incorporate one health promotion activity and one patient education strategy.
• Reflection notes: What would you do differently with this patient if you could conduct the session again? Discuss what your next intervention would be if you were able to follow up with this patient. Also include in your reflection a discussion related to legal/ethical considerations (demonstrate critical thinking beyond confidentiality and consent for treatment!), health promotion, and disease prevention, taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).
• Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differential diagnoses. Be sure they are current (no more than 5 years old).

SOLUTION

S: Subjective

Chief Complaint:
“I feel like I’m losing it. I can’t focus at work, and my mind keeps going back to things that happened years ago.”

HPI (History of Present Illness):
Sherman Tremaine, a 28-year-old African American male, presents with persistent intrusive thoughts, flashbacks, sleep disturbances, irritability, and hypervigilance. He reports that symptoms began approximately four years ago, after a traumatic car accident in which a friend died. He avoided seeking mental health treatment due to stigma and lack of access. His symptoms have intensified over the last six months, especially since a recent work incident triggered memories of the accident. He reports poor sleep (approximately 3–4 hours per night), difficulty concentrating, withdrawal from social interactions, and increased startle response. He denies current suicidal ideation but has experienced passive thoughts of death in the past.

Past Psychiatric History:
None formally diagnosed. Admits to experiencing anxiety and mood instability since the accident.

Family History:
Father with a history of alcohol use disorder; mother with depression (no formal diagnoses confirmed).

Social History:
Single, lives alone, works in IT. No substance use currently. Occasional alcohol use socially. No tobacco or illicit drug use. Grew up in a low-income neighborhood with high exposure to violence.

Medical History:
No chronic medical conditions reported. No current medications.

Allergies:
NKDA

Functional Impact:
Reports that symptoms are affecting his job performance, relationships, and overall quality of life. Has missed work due to poor sleep and anxiety.

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O: Objective

• Well-groomed, appears stated age, restless posture
• Speech: normal rate and volume
• Mood: “anxious and on edge”
• Affect: restricted
• Thought process: linear but tangential when discussing trauma
• Thought content: no delusions or hallucinations
• Insight: limited
• Judgment: fair
• Orientation: Alert and oriented to person, place, time, and situation
• Memory: intact (but intrusive traumatic memories noted)
• No psychomotor agitation or retardation observed

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A: Assessment

Mental Status Examination (MSE):
Sherman appears anxious, hypervigilant, and emotionally restricted. He exhibits avoidant behavior and difficulty discussing trauma, consistent with trauma-related disorders.

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Differential Diagnoses

1. Post-Traumatic Stress Disorder (PTSD) – Primary Diagnosis
   • DSM-5-TR Criteria Met: Exposure to trauma (car accident), intrusive memories, avoidance, negative alterations in mood/cognition, hyperarousal, duration >1 month, functional impairment
   • Pertinent Positives: Flashbacks, nightmares, irritability, avoidance, sleep problems, intrusive thoughts
   • Pertinent Negatives: No psychosis or current substance use
   • Supporting Evidence: APA (2022), ICD-11 and DSM-5-TR guidelines
2. Generalized Anxiety Disorder (GAD)
   • DSM-5-TR Criteria Not Fully Met: While anxiety is present, the focus of anxiety is trauma-specific, not generalized across various domains
   • Ruled Out Because: Not present for at least 6 months in a broad range of contexts
   • Supporting Evidence: Hoge et al., 2021
3. Major Depressive Disorder (MDD)
   • DSM-5-TR Criteria Partially Met: Some anhedonia, low mood, poor concentration
   • Ruled Out Because: Symptoms are secondary to trauma and not pervasive low mood with multiple depressive episodes
   • Supporting Evidence: American Psychiatric Association, 2022

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P: Plan

Psychotherapy:

• Begin trauma-focused CBT (TF-CBT) to address maladaptive beliefs and avoidant behaviors (per guidelines by the APA, 2022).
• Consider EMDR (Eye Movement Desensitization and Reprocessing) after stabilization phase.
• Weekly sessions initially for 8–12 weeks.

Pharmacologic:

• Start Sertraline 25mg daily, titrate up to 50mg after 1 week as tolerated (FDA-approved for PTSD)
• Monitor for side effects: GI upset, sleep disturbances, increased anxiety
• Consider Prazosin 1mg at bedtime if nightmares persist after 2–4 weeks

Non-Pharmacologic:

• Recommend mindfulness-based stress reduction (MBSR) and guided meditation apps (e.g., Headspace)
• Sleep hygiene education: reduce screen time, avoid caffeine before bed

Alternative Therapies:

• Recommend journaling and expressive arts therapy (especially since he is resistant to traditional therapy initially)

Follow-Up:

• Reassess in 2 weeks for medication response and therapeutic engagement
• Consider psychiatric referral if no improvement in 6–8 weeks

Health Promotion Activity:

• Engage Sherman in aerobic exercise (30 minutes, 5x/week), which has been shown to reduce PTSD symptoms (Rosenbaum et al., 2020)

Patient Education:

• Educate about PTSD symptoms, treatment options, and importance of medication adherence
• Discuss the temporary nature of side effects and the need for regular follow-up

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Reflection Notes

If I could repeat the session, I would spend more time building rapport and normalizing therapy as a supportive process rather than something stigmatizing. Sherman expressed reluctance initially, likely due to cultural mistrust and male norms around mental health. I would consider introducing motivational interviewing techniques earlier in the session.

Next Step:
Monitor treatment adherence, introduce group therapy for trauma survivors, and screen for substance use again at next visit.

Legal/Ethical Considerations:
Confidentiality was maintained, but an important ethical aspect includes addressing cultural humility and recognizing systemic barriers Sherman faces as a young African American male. Providers must be cautious not to overpathologize behaviors rooted in socioeconomic or racial trauma.

Health Promotion & Disease Prevention:
Considering Sherman’s age, race, and socioeconomic background, interventions should be accessible, culturally sensitive, and trauma-informed. Assess for ACEs (Adverse Childhood Experiences) and connect with community-based resources for long-term support.

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References

Focused SOAP Note: Sherman Tremaine