The HPI (History of Present Illness) that came with my discharge paperwork states:
Patient is a 32 year old female VAB with a past psych history of PTSD following several episodes of sexual abuse who was admitted to ______ for _______ overflow from the V.A. outpatient psych for worsening SI over the past 4 weeks. Four months ago the patient started dating a man, who is now her fiance and is 100% SC for PTSD, that has tried to help her with her PTSD. Over the past four months , her PTSD symptoms, to include hyper-vigilance and nightmares / flashbacks, have become worse. Of note, she reports that all men in uniform cause her significant anxiety. Over the past four weeks, she has started having SI that has progressively gotten worse. She reports that she has thoughts of worthlessness and thoughts that her family would be better off if she wasn't here. She denies any current or active plans for suicide. She does have a history of cutting, while she was AD for a period of 3-4 years. Currently patient is unemployed and quit her volunteer job in January after a disagreement with management.
Her PTSD was from events during a two year period from 2000-2002 (when I was AD), while the patient was stationed in Germany. She was an E-3 and the assailent was an E-6. She reports that he raped her twice, stalked her, and harassed her while at work and at her place of residence. She has not yet received any treatment, or counseling for these events. Additionally, she reports blocking out much of her memories about the events, only resurfacing now as she talks to her fiance. Additionally she reports having a breast reduction to decrease the attention that she has received from men.
She reports having depressed mood. Additionally, she has difficulty sleeping (nightmares, trouble falling asleep), loss of interest in daily activities, decrease in energy, poor concentration, significant decrease in appetite (loss of 5-10 over the past couple of weeks), some psychomotor agitations (hand tremor, hand wringing), and SI as described above. SIGECAPS +8/9. Denies feelings of guilt.
Reports no drinking in the past four years and prior to that was a social drinker (1 to two drinks per week). While AD, reports alcohol abuse. Reports having administrative actions taken against her by command for drinking while on quarters, Need to drink to fall asleep, etc.
No illicit drug use.
Quit smoking 4 months ago.
Will this help me with my claim?
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