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Kelvin
I had this done back in May, Im confused on if I have PTSD or Depression. Pls let me know what this is. XXXX (Took my name out)
Chief Complaint: Depression, intrusive thoughts Present Illness: 45-year-old veteran who is 80% SC overall but has no psychiatric disabilities. Had no history of mental health treatment until referred to a mental health social worker at the JACC with whom XXXX met on February 5th of this year. Social worker documented at that time: "Patient reported that he had been having dreams about an event that occurred while active duty off the coast of Africa. Patient reported that while aboard the USS Firebolt they came across a boat full of refugees that capsized as they were attempting to board the ship. He reported that a child was thrown to him from another crew member who was onboard a smaller patrol boat and he dropped the child into the water. He reported that he watched the child go under the boat. He reported he also witnessed a woman who was too weak to climb onboard the boat and he watched her go under the boat. He reported that he could have saved them
had he gone into the water, however the crew members had been given orders not to leave the boat. He reported that he had never talked to anyone about this until last year when he told his spouse. This was the first time disclosing it to someone other than her. Patient reported that he had been isolating himself from his spouse." XXXX was referred to the counselor at this clinic with whom he's met on three occasions and will be beginning IPT in the near future. XXXX continues to experience depressed mood, irritability, isolative behaviors, intrusive thoughts, and occasional nightmares. His isolation stems more from his irritability than from avoidance of particular triggers, although he does admits having difficulty going to the beach. XXXX cites a number of issues in his current relationship with his wife as they live with two teenagers who from his wife's previous marriage. XXXX and his wife differ on expectations from and discipline of the children which has caused more than one verbal conflict. Finds himself more irritable at work as well which has led to his being more verbally impulsive. Has never sought help for his mood in thepast and is not particularly clear why he sought help recently. Past Psychiatric History: No history of treatment prior to his evaluation in February. Denies history of SI/SA. Denies history of substance use.
MENTAL STATUS EXAMINATION:
The veteran appeared well-developed, well-nourished, clean, and dressed appropriately. The veteran was alert and oriented in all spheres and able to establish rapport. Eye contact was adequately maintained and there was
no obvious psychomotor abnormality. Mood was "sad". Affect was reactive and congruent. Speech was fluent and normal in tone, rate and volume. Thought processes were logical and goal-directed with intact associations. There was no evidence of thought disorder or perceptual disturbances. There was no expressed delusional content. Suicidal and homicidal ideations were denied within the past thirty days and there has been no self-injurious behavior. Immediate, recent and remote memories were grossly intact as was attention and concentration. Insight was good. Judgment and impulse control were adequate.DIAGNOSTIC IMPRESSION (DSM-5):
MDD, recurrent, mild Could certainly consider diagnosis of PTSD given XXXX's experience, although he doesn't exhibit the hypervigilance, exaggerated startle response, and their appears to have been elements in his history that would be more consistent with a major depressive disorder that has been ongoing for some time but perhaps exacerbated by his traumatic experiences. From a medication standpoint this distinction is not likely to be particularly important however. After discussion about various treatment options will provide trial of Sertraline, but XXXX was encouraged to remain engaged in the psychotherapeutic milieu.
PLAN:
Start Sertraline 50mg po daily
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Gastone
The VA will provide whatever MH treatment you need, I was 70% PTSD, opted for Group Therapy rather than a Psychiatrist. After 2 1/2 yrs of weekly therapy, still had the PTSD issues but had a better u
broncovet
You are diagnosed with MDD (depression). The doc says you MAY also have PTSD, but the difference between depression and PTSD is not important in your treatment. Its also not an important diffe
Gastone
While PTSD isn't a necessary component of a Clinical Depression DX, Depression seems to be always a component of a PTSD DX. I trust you have, by now, filed a PTSD FDC, right? It will all come dow
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