Ok everyone, I went to the VA today and got my papers from my recent exam. This will be alot of typing, so bear with me my mispellings. I'm going to Pass through some of the past stuff and just get to what he saw in my exam.
Frequency, severity and duration of Non-PTSD Psychiatric Medical Symptoms: Generally, his mood has been down and depressed, he is not sure why he is down other than some troubles at work. Has had issues dealing with people in the place. Feels nervous much of the time, as well.
Legal History? No
Educational Accomplishments? No
Description of Marital and Family Relationships: Trouble getting along with his wife. "I get on her nerves, I guess" Tends to yell at her when she is driving. Gets along fairly with siblings and Parents are deceased.
Description of degree and quality of social Relationships: Most of his friends are being deployed; i.e, 2-3 friends. No civilian friends
Description of activities and leisure pursuits: No active hobbies or interets, "I basiclally take care of my kid" Used to be interested in fishing and hunting...but "fishing agitates me" and don't like shooting stuff anymore.
History of Suicide Attempts? Yes. *Going to leave this one out due to personal reasons* B)
History of Violence/Assaultiveness? Yes "I tend to throw stuff" Does not hit people or throw things at people.
Issues associated with alcohol use: When he drinks, he drinks more than he plans to, may drink up to 18 beers. Last did at a wedding in Oct, 09
No substance abuse
Psych Exam
General Appearance:
Casually dressed, Other
Description of any other appearance characteristics, Har was mussed from his hat; not shaved; smelled of smoke and mild BO
Psychomotor Activity: Restless, Other
Description of any other psychomotor activitiy: Foot was bouncing; sweaty hands
Speech: Hesitant, clear, coherent
Attitude toward examiner: Cooperative, Other
Description of any other attitude: Seemed tense, comes accross as immature
Affect: Full
Mood: Anxious, hopeless, depressed, dysphoric, Other
Description of any other mood: Comes across as negative and complaining.
Able to do Serial 7's? No (Counting backwards by 7 from 100)
Able to spell a word forward and backward? Yes
Comments: Rates his concentration as poor, has affected his ability to drive, as drives past where he is supposed to be going. Has trouble keeping on a single task at work.
Orientation:
Intact to person: Yes
Intatct to time: Yes
Intact to place : Yes
Delusions: None
Judgement: Understands outcome of behavior
Intelligence: Avg.
Insight: Patient understands that he/she has a problem
Does the patient have sleep Imparment? Yes
Says he has not slept very good over past month; has nightmares "just about every night" Takes a long time to get to sleep. I get alot of thoughts in my head, such as work the next day.
Average 3-5 hours of sleep per night, never feels rested. During the day it stresses me out
Innapropriate behavior? Yes
Has trouble controlling his comments when he is dealing with people, his (illegible) tells him he is too harsh
Interprets Proverbs Appropriately? No
Explanation: Very concrete
Obsessive/ritualistic behavior? No
Panic Attacks? Yes
Frequency severity, duration and effects on functioning: Claims he has panic attacks "a lot" one reason he takes hydroxyzine; may increase when someone at work will point guns at him. Sometimes at home..he might wake up with his heart racing
Homicidal Thoughts: No
Suicidal Thoughts: Yes, 5-6 times per week
Extent of impulse control: Fair
Examples of effects on motivation/mood
When his mother was passing away, he went out and bought a suv. Usually does not use money impulsively. Make go for drives on a whim. (This examiner is judging me on my grammar, intelligence, yet he cannot type out a logical sentince... Just found this funny)
Ability to Maintain minimum personal hygene? No
Comments, Showers once every 4-5 days
Wife complains about his hygine "All the time" i.e. about his clothes, teeth
I there problem with activities of daily living? Yes
Household chores: Moderate
Toileting: none
Grooming: Moderate
Shopping: Moderate
Bathing: Moderate
Dressing/undressing:Slight
Driving:Moderate
Description of other problem with activities of daily living: Tends to avoid driving, has road rage and inattentiveness.
Comemnts or elaboration of any items int he MSE or for items not covered or other comments:
Self esteem is "Pretty Low" gets feeling that people do not care about him or want to talk to him
Appetite is good enough to eat once per day.
Weight is down by 5-10 pounds over past two months, with intentional effort
Memory:
Remote:Normal
Recent:Mildly impared
Immediate: Mildly Impared
Persistent Re-experiencing the traumatic event by:
Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions, Recurrent distressing dreams of the event. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event, physiological reach on exposure to tinernal or external cues that symbolize or resemble an aspect of the traumatic event.
Persistent avoidance of stumuli associated with the trauma and tumbing of GE Responsiveness:
Efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that arounse recollection of the trauma. Markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted of affect. E.G. Unable to have loging feelings
Persistent symptoms of increased arousal: Difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypevigilance, exaggerated startle respons
Description of fthe onset Symptoms: Chronic
Frequency, Severity and duration of ptsd symptoms Found: Almost every day he has intrusive memories, Stuff I could have done different, including one about a tanker fire. Has trigered memories from explosions or "Bangs"
Tries not to think about what happened; side tracks himself by watching TV not like talking about what happened. Avoids being in loud places or crowded places. Feels disconnected with most people.
Length of remissions, etc: None noted.
Then it continues about asking if I know amounts of benefits, bills etc. All were "YES" except Personally handling money and paying bills
He handed over the responsibilities because he was getting frustraded, when he does he sets up automatic payments.
Is a social work assessment necessary to render an opinion? No
Employment History...
Currently employed? Yes
Clerk
Part time
Less than 1 year
Time lost from work durning last 12 month period: Has missed work, calls in when he does not sleep or "just not wanting to (cut off)
before that, security guard (very part time) for about a year, until he was fired for "disobeyeing some order" he had had problems getting along with his coworkers.
Problems related to occupational functioning: Decreased concentration, increased abesnteeism, poor social interaction
Does the veteran meet the dsm-IV Stressor Criterion? Yes
Description of the primary stressors related to PTSD: Combat
Does the veteran meet the dsm-IV criteria for a diagnosis of PTSD? Yes
Axis I : PTSD; Major deperessive disorder, recurrent, mild to moderate
Axis II: Deferred
Axis III See medical records
Axic IV : WOrk stress
Axis V: GAF
Score: 50Time Frame: Current funcitioning
Changes in functional status and quality of life since last exam: Performance in employment, routine responsibilities of self-care, family role functioning, Social/interpersonal relationships, Recreation/leisure pursuits
Comments concerning Functional status and quality of life: Trouble functioning at work usually du e to high anxiety and interpersonnal issues
Displays marginal hygene, has trouble getting on things
Has very little involvement with other people; socially isolated. No acting on recreational pursuits. Ongoing strain with his wife, due to irritability
Description of linkage between PTSD symptoms and aforementioned changes in imparement in fuctional state, and quality of life: Trouble functioning at work, usually due to high anxiety and interpersonal...
Has very little involvement with other people. socially Isolated. no active... same as above
State prognosis for improvement of psychiatric condition and imparements in functional status
Prognosis appears fair
PTSD REVIEW: Effects of PTSD on Occupational and Social Functioning
Is there total occupational an d social imparement due to ptsd signs and symptoms? NO
If there is not total occupational and social imparement, do ptsd signs and symptoms result in deficiencies in the following areas (Judgement, Thinking, RElations, Work, Mood, or School? Yes
Judgement? Yes
Examples including those already reported: Displays road rage when driving or riding in a vheicle; says things he regrets when he gets frustraded with people at work or at home
Thinking? Yes
Examples: Easily side tracked when he is doing things; tends to get preoccupied, has poor mentla staminda due to anxiety and low moods
Family Relations? Yes
Examples: Strained relationship with his wife, due to his irritability.
Work? Yes
Examples: Problems coping with stress at work; gets irritable with customers and coworkers.
Mood? Yes
Examples: Persistently depressed and anxious, very hypervigilant in public place. Startles easily with noise and commotion, to point he feels overwhelmed.
School? N/A
Was a medial opinion requested? NO
So this was my exam. i don't know what the Axis things were. If any of you have any opinions on my exam let me know. I'm currently at 50% PTSD, this was my appeal interview, so I'm hoping to get up to 70. Let me know what you all thing. My hands are tired now, so I'm going to rest them...lol
Question
Sapper
Ok everyone, I went to the VA today and got my papers from my recent exam. This will be alot of typing, so bear with me my mispellings. I'm going to Pass through some of the past stuff and just get to what he saw in my exam.
Frequency, severity and duration of Non-PTSD Psychiatric Medical Symptoms: Generally, his mood has been down and depressed, he is not sure why he is down other than some troubles at work. Has had issues dealing with people in the place. Feels nervous much of the time, as well.
Legal History? No
Educational Accomplishments? No
Description of Marital and Family Relationships: Trouble getting along with his wife. "I get on her nerves, I guess" Tends to yell at her when she is driving. Gets along fairly with siblings and Parents are deceased.
Description of degree and quality of social Relationships: Most of his friends are being deployed; i.e, 2-3 friends. No civilian friends
Description of activities and leisure pursuits: No active hobbies or interets, "I basiclally take care of my kid" Used to be interested in fishing and hunting...but "fishing agitates me" and don't like shooting stuff anymore.
History of Suicide Attempts? Yes. *Going to leave this one out due to personal reasons* B)
History of Violence/Assaultiveness? Yes "I tend to throw stuff" Does not hit people or throw things at people.
Issues associated with alcohol use: When he drinks, he drinks more than he plans to, may drink up to 18 beers. Last did at a wedding in Oct, 09
No substance abuse
Psych Exam
General Appearance:
Casually dressed, Other
Description of any other appearance characteristics, Har was mussed from his hat; not shaved; smelled of smoke and mild BO
Psychomotor Activity: Restless, Other
Description of any other psychomotor activitiy: Foot was bouncing; sweaty hands
Speech: Hesitant, clear, coherent
Attitude toward examiner: Cooperative, Other
Description of any other attitude: Seemed tense, comes accross as immature
Affect: Full
Mood: Anxious, hopeless, depressed, dysphoric, Other
Description of any other mood: Comes across as negative and complaining.
Attention: Attention Disturbance (Easily Distracted) Attention Disturbance (Short Attention Span)
Able to do Serial 7's? No (Counting backwards by 7 from 100)
Able to spell a word forward and backward? Yes
Comments: Rates his concentration as poor, has affected his ability to drive, as drives past where he is supposed to be going. Has trouble keeping on a single task at work.
Orientation:
Intact to person: Yes
Intatct to time: Yes
Intact to place : Yes
Delusions: None
Judgement: Understands outcome of behavior
Intelligence: Avg.
Insight: Patient understands that he/she has a problem
Does the patient have sleep Imparment? Yes
Says he has not slept very good over past month; has nightmares "just about every night" Takes a long time to get to sleep. I get alot of thoughts in my head, such as work the next day.
Average 3-5 hours of sleep per night, never feels rested. During the day it stresses me out
Innapropriate behavior? Yes
Has trouble controlling his comments when he is dealing with people, his (illegible) tells him he is too harsh
Interprets Proverbs Appropriately? No
Explanation: Very concrete
Obsessive/ritualistic behavior? No
Panic Attacks? Yes
Frequency severity, duration and effects on functioning: Claims he has panic attacks "a lot" one reason he takes hydroxyzine; may increase when someone at work will point guns at him. Sometimes at home..he might wake up with his heart racing
Homicidal Thoughts: No
Suicidal Thoughts: Yes, 5-6 times per week
Extent of impulse control: Fair
Examples of effects on motivation/mood
When his mother was passing away, he went out and bought a suv. Usually does not use money impulsively. Make go for drives on a whim. (This examiner is judging me on my grammar, intelligence, yet he cannot type out a logical sentince... Just found this funny)
Ability to Maintain minimum personal hygene? No
Comments, Showers once every 4-5 days
Wife complains about his hygine "All the time" i.e. about his clothes, teeth
I there problem with activities of daily living? Yes
Household chores: Moderate
Toileting: none
Grooming: Moderate
Shopping: Moderate
Bathing: Moderate
Dressing/undressing:Slight
Driving:Moderate
Description of other problem with activities of daily living: Tends to avoid driving, has road rage and inattentiveness.
Comemnts or elaboration of any items int he MSE or for items not covered or other comments:
Self esteem is "Pretty Low" gets feeling that people do not care about him or want to talk to him
Appetite is good enough to eat once per day.
Weight is down by 5-10 pounds over past two months, with intentional effort
Memory:
Remote:Normal
Recent:Mildly impared
Immediate: Mildly Impared
Persistent Re-experiencing the traumatic event by:
Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions, Recurrent distressing dreams of the event. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event, physiological reach on exposure to tinernal or external cues that symbolize or resemble an aspect of the traumatic event.
Persistent avoidance of stumuli associated with the trauma and tumbing of GE Responsiveness:
Efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that arounse recollection of the trauma. Markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted of affect. E.G. Unable to have loging feelings
Persistent symptoms of increased arousal: Difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypevigilance, exaggerated startle respons
Description of fthe onset Symptoms: Chronic
Frequency, Severity and duration of ptsd symptoms Found: Almost every day he has intrusive memories, Stuff I could have done different, including one about a tanker fire. Has trigered memories from explosions or "Bangs"
Tries not to think about what happened; side tracks himself by watching TV not like talking about what happened. Avoids being in loud places or crowded places. Feels disconnected with most people.
Length of remissions, etc: None noted.
Then it continues about asking if I know amounts of benefits, bills etc. All were "YES" except Personally handling money and paying bills
He handed over the responsibilities because he was getting frustraded, when he does he sets up automatic payments.
Is a social work assessment necessary to render an opinion? No
Employment History...
Currently employed? Yes
Clerk
Part time
Less than 1 year
Time lost from work durning last 12 month period: Has missed work, calls in when he does not sleep or "just not wanting to (cut off)
before that, security guard (very part time) for about a year, until he was fired for "disobeyeing some order" he had had problems getting along with his coworkers.
Problems related to occupational functioning: Decreased concentration, increased abesnteeism, poor social interaction
Does the veteran meet the dsm-IV Stressor Criterion? Yes
Description of the primary stressors related to PTSD: Combat
Does the veteran meet the dsm-IV criteria for a diagnosis of PTSD? Yes
Axis I : PTSD; Major deperessive disorder, recurrent, mild to moderate
Axis II: Deferred
Axis III See medical records
Axic IV : WOrk stress
Axis V: GAF
Score: 50Time Frame: Current funcitioning
Changes in functional status and quality of life since last exam: Performance in employment, routine responsibilities of self-care, family role functioning, Social/interpersonal relationships, Recreation/leisure pursuits
Comments concerning Functional status and quality of life: Trouble functioning at work usually du e to high anxiety and interpersonnal issues
Displays marginal hygene, has trouble getting on things
Has very little involvement with other people; socially isolated. No acting on recreational pursuits. Ongoing strain with his wife, due to irritability
Description of linkage between PTSD symptoms and aforementioned changes in imparement in fuctional state, and quality of life: Trouble functioning at work, usually due to high anxiety and interpersonal...
Has very little involvement with other people. socially Isolated. no active... same as above
State prognosis for improvement of psychiatric condition and imparements in functional status
Prognosis appears fair
PTSD REVIEW: Effects of PTSD on Occupational and Social Functioning
Is there total occupational an d social imparement due to ptsd signs and symptoms? NO
If there is not total occupational and social imparement, do ptsd signs and symptoms result in deficiencies in the following areas (Judgement, Thinking, RElations, Work, Mood, or School? Yes
Judgement? Yes
Examples including those already reported: Displays road rage when driving or riding in a vheicle; says things he regrets when he gets frustraded with people at work or at home
Thinking? Yes
Examples: Easily side tracked when he is doing things; tends to get preoccupied, has poor mentla staminda due to anxiety and low moods
Family Relations? Yes
Examples: Strained relationship with his wife, due to his irritability.
Work? Yes
Examples: Problems coping with stress at work; gets irritable with customers and coworkers.
Mood? Yes
Examples: Persistently depressed and anxious, very hypervigilant in public place. Startles easily with noise and commotion, to point he feels overwhelmed.
School? N/A
Was a medial opinion requested? NO
So this was my exam. i don't know what the Axis things were. If any of you have any opinions on my exam let me know. I'm currently at 50% PTSD, this was my appeal interview, so I'm hoping to get up to 70. Let me know what you all thing. My hands are tired now, so I'm going to rest them...lol
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