The patient is a 28 y/o male veteran of the Iraq war who served two tours of duty. He was referred to the VA Outpatient Behavioral Health Center for psychiatric evaluation from a civilian provider. He has been seen by me on a once weekly basis for the past 3 weeks. Initial psychiatric evaluation 3 weeks ago revealed he experienced combat and survived two improvised explosive device (IED) explosions while riding in military vehicles. Four fellow service friends were killed in the two vehicle explosions. After returning from Iraq two years ago, the patient began experiencing anxiety-like symptom experiences. The patient has not received psychiatric counseling in the past, prior to his care here, and denies a family history of psychiatric conditions. Today, he also reports having trouble getting along with his family members and coworkers in his civilian job because of his angry outbursts over relatively minor things. He describes himself as emotionally numb and although not suicidal, he questioned why Im still here. He remains tobacco dependent and drinks approx. 5 beers over the course of a weekend. PE: Behavior is cooperative with fair eye contact. There is no evidence of auditory, visual, or olfactory hallucinations. His general appearance was within normal limits, well-groomed and appropriately dressed. His attention span and concentration is WNL. Speech was slightly labored. Mood and affect are congruent. Memory is intact. His judgment is not impaired. He no longer endorses thoughts of suicide. He remains motivated to continue psychotherapy. Today he has complaints of increased difficulty falling and staying asleep, with only achieving approximately 3-4 hours of sleep per night for the last 10 days. He routinely sleeps 6-7 hours per night. Vital signs, BP 110/72 pulse 62, resp. 20. Muscle strength and tone were normal. Gait; normal.
This session was aimed at focusing on triggers of his outbursts with co-workers. The patient shared examples of these triggers and acknowledged how others could misunderstand his statements and thus create tension with co-workers. Methods of how to improve his communication skills were discussed with trauma-focused psychotherapy including prolonged exposure techniques by facing negative feelings and talking about the trauma and thought avoidance in order to cope. Also used cognitive processing therapy to reframe negative thoughts. We discussed anger management techniques when dealing with family and work associates such as deep breathing and walking away for a period of time until negative emotions are under control. He was enthusiastic about incorporating above into his daily interactions with others. Time spent with patient on supportive psychotherapy was 45 minutes of the one hour appointment.
A/P: Post Traumatic Stress Disorder, decompensated, cigarette smoking. Continue weekly psychotherapy. Continue medication Venlafaxine 50 mg PO daily. CBC and Urinalysis were ordered. Begin taking Ambien 5 mg. PO at bedtime #15 prescribed to begin with.