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hypertension Ptsd C&p Back In March Possible Raing
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maine2000
Here are some of the things in the report.What do you guys think of this report?
03/19/2011 INITIAL EVALUATION FOR POST-TRAUMATIC STRESS DISORDER (PTSD)
Priority of Exam: ORIGINAL SC
Examination results:
EXAMINATION TYPE: Stress disorder.
PRIORITY OF EXAMINATION: Original.
The C-file was reviewed in its entirety.
HISTORY OF PRESENT ILLNESS: The Veteran, who carries a diagnosis of
posttraumatic stress disorder, experienced an incident in which there was an
explosion aboard the ship he was working, and he watched another sailor burn to
death. The Veteran was evaluated previously
on 11/23/10. Dr.diagnosed the patient with posttraumatic stress
disorder and gave him a global assessment of functioning of 54. She verified
that his symptoms were related to this explosion aboard ship. The Veteran
continues to complain of intrusive recollections of the traumatic event . He
reports having nightmares every night. He is taking medication that helps him
sleep and without medication, he is unable to sleep. He has flashbacks during
the daytime with olfactory hallucinations of flesh burning. He reports feeling
anxious and depressed when reminded of this soldier's death. The Veteran
avoids thinking about or being reminded of this event. The Veteran states that
he continues to feel very emotionally apart from others. He is very irritable
and has become physically violent as recently as in the last week. He has
difficulty concentrating and problems with his short-term memory. He startles
very easily and is extremely watchful in crowds. He states he has thoughts
frequently of suicide. He is medicated with citalopram and trazodone.
He is treated at the VA. He denies a history of family psychiatric problems.
He denies abuse of alcohol or drugs.He did have a history of using alcohol to excess
but no longer drinks at all.
SOCIAL HISTORY: The Veteran lives at various homes between different family
members. He was born in SC and raised by both of his parents. He
graduated from high school. He works part-time for a company that does
computer work for dental offices. He is able to perform all activities of
daily living.
MEDICAL HISTORY: The Veteran has hypertension, right shoulder pain, leg pain,
and back pain.
MENTAL STATUS EXAMINATION: The Veteran is an adequately groomed male,
appearing his stated age. He is somewhat guarded during the interview and
appears anxious. He maintains intermittent eye contact with the examiner. He
exhibits some psychomotor restlessness. His speech is rapid at times .
He describes his mood as very down. His affect is blunted. His thoughts are
generally organized with some circumstantiality. He has chronic suicidal
thoughts but no intent at this time. He has olfactory hallucinations when
experiencing flashbacks. His concentration is impaired. His short - term memory
is impaired. His intelligence is average. His insight and judgment are
somewhat impaired.
DIAGNOS I S: Axis I: Posttraumatic stress disorder, chronic. Axis II: No
diagnosis. Axis III: See medical history portion of report. Axis IV:
Family, social, occupational, economic problems. Axis V: The Veteran's
current global assessment of functioning is 55.
The Veteran is able to manage VA benefits.
OPI NIONS: It is the opinion of the evaluator that the Veteran's posttraumatic
stress disorder is secondary to an incident that occurred while he was on
a ctive duty but is not related to his fear of hostile military or terrorist
activity.
11/23/2010 INITIAL EVALUATION FOR POST-TRAUMATIC STRESS DISORDER (PTSD)
Priority of Exam: ORIGINAL SC
11/24/2010 The first C&P
Examination results:
MEDICAL HISTORY AND HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old,
married one time but separated, African-American male who presents for an
evaluation to establish service connection for posttraumatic stress disorder.
When questioned about what brought him to evaluation, he says he has mental
health problems. The claims file was available at the time of the evaluation
and was reviewed by this clinician. It provided evidence of his claim for
PTSD. There was a statement in support of his claim. There were notes from
the VA Clinic. It was noted that the Veteran has been diagnosed
with PTSD. There was a rule out of bipolar and a substance-induced mood
disorder. There was PTSD and a rule out of alcohol abuse from DR.
There was a statement in support of the Veteran's claim talking about the
incident on the ship with an explosion and his anxiety and PTSD is a result of
that and it was noted that he has been diagnosed also with depression and
prescribed citalopram. There was a treatment plan from the DR and
treatment notes. The Veteran denied a family history of mental illness and
denied a history of trauma prior to service in the military. For additional
information about his current symptoms, please refer to the discussion section
o f the report. Medically, the Veteran reported that he has hypertension, pain
in his right shoulder, his legs, his feet, and chest pain from his shoulder.
PAST PSYCHIATRIC HISTORY: The Veteran reported that he has seen in
the past for counseling and now he has a new medication provider that he sees
SOCIAL AND OCCUPATI ONAL HISTORY: The Veteran suggested that he lives in SC
. He noted that he completed high school. He described military service
in the Navy from August 1989 to July 1993 where he was a Navy Aviation
Boatswain ' s Mate . He reported that he was in the Middle East during Desert
Storm . He reported a traumatic incident that happened in August 1991 . He said
that they were out to sea and a sailor was blown up on the ship from liquid
oxygen bottle and he saw his body. He said that when he heard the explosion he
worried that the ship was going to sink and he feared for his life. In terms
of his work history, he said he works. He has been there for a year. He denied he has missed
any time from work because of PTSD other than for appointments. He denied
problems with irritability. He says he can have some trouble with
concentration on the job that can slow him down and cause him t o make mistakes.
He denied a history of legal involvement. When questioned about his use of
addictive substances , he denied using drugs. When questioned about his relationships with others,
he reported that he has been married 1 time but he has been separated for 5
years and he has an 8-month-old daughter. He says he lives between his parents
house and his girlfriend 's house but more with his girlfriend. The
relationship with his girlfriend is fair. He says he can be irritable and
withdrawing sometimes. He says the relationship is good with his daughter. He
described a fair relationship with his parents because of his withdrawal and
irritability . He says he has 2 close friends and they talk. He talks to one
of them every 4 months because he lives out of state and the other he sees
about once every 2 weeks. He says he watches sports on TV and he spends time
on the computer . He has fished about twice in the past year. He does some
cooking and cleaning and spends time with his daughter.
MENTAL STATUS EXAMINATION: The Veteran was alert, oriented and attentive ana
appeared his stated age. His mood appeared to be dysphoric and his affect was
constricted. His speech was of regular rate and rhythm. There was no evidence
of psychomotor agitation or retardation. The Veteran's eye contact was fair.
He was cooperative and pleasant with the examiner . His thought process was
logical and coherent . His thought content was devoid of current auditory or
visual hallucinations. No evidence of delusional content was noted. He denied
current thoughts of hurting himself or hurting others. Denied a history of
suicide attempts and said the last time he was physically aggressive with
somebody was last week. He did say that he sometimes has passive suicidal
ideat i on in the face of a lot of stress but he is able to push the ideation
aside. His intelligence is estimated to be in the average range
and the Veteran had fair insight into his current condition.
DIAGNOSTIC IMPRESSION: Axis I: Posttraumatic stress disorder. Axis II:
Deferred. Axis III: Per the Veteran's report hypertension and pain in his
right shoulder, his legs, feet and chest pain from his shoulder. Axis IV:
Relationship problems and some difficulties with employment. Axis V: A GAF
score currently of 54.
DISCUSSION: This Veteran is exhibiting moderate to at times moderate to
considerable symptoms associated with PTSD. His PTSD appears to be related to
the above- mentioned stressor in which he feared for his life but it does not
appear to be related to fear of hostile military activity. Specifically, he
reported intrusive thoughts of his trauma twice a month and nightmares 1 time
every 2 weeks. He described psychological and physiological reactivity to some
loud noises or seeing fire or fire on TV. He says he does not like to talk or
think about his trauma and avoids crowds. His affect was constricted. He
described emotional detachment from others and less interest in activities. He
says he sleeps about 4 hours and has trouble concentrating. He reported an
exaggerated startle reaction to loud noises or unexpected approaches in a
hypervigilant style. He reported depressive symptoms in the past but he says
the depression lasted no more than a couple of days except when he was using
alcohol heavily. He says he has had his symptoms since 1992. He feels his
symptoms have gotten worse. He denied periods of remission and denied problems
with activities of daily living such as feeding, bathing or toileting himself.
In terms of his social adaptability and interactions with others, this appears
to be moderately to moderately to considerably impaired. In terms of his
ability to maintain employment and perform job duties in a reliable/efficient
manner, this appears to be moderately impaired. Overall, I would estimate his
level of disability to be in the moderate to moderate to considerable range and
I would say the Veteran is capable of handling his own funds.
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