What is a sample SOAP (Subjective, Objective, Assessment, Plan) note for a patient undergoing inpatient detoxification from alcohol and Post-Traumatic Stress Disorder (PTSD)?

Sample SOAP Note for Inpatient Detoxification from Alcohol with PTSD

Subjective

• Patient reports heavy alcohol consumption (specify amount/frequency) for past [X] years with increased consumption in recent months 1
• Reports multiple failed attempts to quit drinking independently 1
• Endorses withdrawal symptoms when attempting to stop drinking including tremors, anxiety, insomnia, and diaphoresis 2
• Reports traumatic event(s) (specify nature if disclosed) occurring [timeframe] 1
• Describes PTSD symptoms including intrusive thoughts, nightmares about trauma, hypervigilance, avoidance behaviors, and emotional numbness 1, 3
• Patient acknowledges using alcohol to cope with PTSD symptoms, particularly to avoid trauma reminders and manage anxiety 4, 5
• Reports sleep disturbances including difficulty falling asleep, frequent nighttime awakenings, and trauma-related nightmares 1
• Denies current suicidal/homicidal ideation, but reports periods of hopelessness

Objective

• Vital signs: BP [value], HR [value], RR [value], Temp [value], O2 sat [value]
• CIWA-Ar score: [value] (indicating moderate/severe withdrawal requiring medication) 2
• AUDIT score: [value] (scores >9 predict clinically meaningful withdrawal symptoms) 2
• PCL-5 score: [value] (indicating severity of PTSD symptoms) 4
• Physical exam findings: [note tremors, diaphoresis, tachycardia, or other relevant findings]
• Laboratory results:
  • CBC: [relevant findings]
  • CMP: [relevant findings, especially liver function tests]
  • BAC: [value] mg/dL
  • Urine toxicology: [results]

Assessment

1. Alcohol Use Disorder, severe (DSM-5 criteria met) with physiological dependence requiring medical detoxification 1
2. Alcohol withdrawal, [mild/moderate/severe] based on CIWA-Ar score 2
3. Post-Traumatic Stress Disorder (DSM-5 criteria met) 1, 3
4. Co-occurring PTSD and AUD with evidence that patient uses alcohol specifically to cope with PTSD avoidance symptoms 4, 5
5. [Any other relevant medical or psychiatric diagnoses]

Plan

Alcohol Detoxification Protocol

1. Benzodiazepine regimen for alcohol withdrawal management using symptom-triggered approach with CIWA-Ar monitoring every 1-2 hours 1

   • Medication: [Lorazepam/Diazepam/Chlordiazepoxide] [dose] [frequency] based on CIWA-Ar scores
   • Taper schedule over [5-7] days as withdrawal symptoms resolve

2. Supportive care:

   • IV fluids as needed for hydration 6
   • Thiamine 100mg IV/PO daily × 3-5 days, then PO 1
   • Folate and multivitamin supplementation 1
   • PRN medications for symptomatic relief (antiemetics, analgesics) 6

PTSD Treatment Plan

1. Initiate evidence-based psychotherapy for PTSD once patient is medically stable, with priority given to Prolonged Exposure, Cognitive Processing Therapy, or Eye Movement Desensitization and Reprocessing 1, 3

2. Consider pharmacotherapy for PTSD:

   • Paroxetine, sertraline, or venlafaxine are recommended first-line medications for PTSD symptoms 1, 3
   • Avoid benzodiazepines for long-term PTSD management despite their use in acute alcohol withdrawal 1, 3
   • Avoid cannabis and cannabis-derived products 1

3. Specific interventions for trauma-related nightmares:

   • Consider Imagery Rehearsal Therapy (IRT) or Exposure, Relaxation, and Rescripting Therapy (ERRT) 1
   • Progressive Deep Muscle Relaxation training 1

Maintenance of Alcohol Abstinence

1. Initiate acamprosate (666mg TID) once withdrawal symptoms have resolved to maintain abstinence 1

   • Evidence shows acamprosate is the most effective medication for maintaining abstinence with moderate certainty 1

2. Consider naltrexone as an alternative or in combination with acamprosate for patients with high risk of relapse 1

3. Psychosocial interventions:

   • Cognitive Behavioral Therapy focusing on both alcohol use and PTSD symptoms 1
   • Motivational Enhancement Therapy 1
   • Coping skills training specifically addressing trauma-related alcohol use 5

Discharge Planning

1. Begin discharge planning early (at least 1 month before anticipated discharge if possible) 1

2. Ensure continuity of care:

   • Schedule follow-up appointments with outpatient providers 1
   • Provide adequate medication supply until first follow-up appointment 1
   • Provide written summary of current treatment plan and medications 1

3. Connect patient with community resources:

   • Alcoholics Anonymous or SMART Recovery 1
   • Veteran-specific resources if applicable 1, 3
   • PTSD support groups 1

4. Relapse prevention education focusing on the relationship between PTSD symptoms and alcohol use 4, 5