84 lines
4.1 KiB
Mathematica
84 lines
4.1 KiB
Mathematica
DVBCWPE1 ;ESW/ PTSD WKS TEXT - 1 ; 9 Oct 2000
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;;2.7;AMIE;**34**;Apr 10, 1995
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TXT ;
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;;
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;;A. Review of Medical Records
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;;
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;;B. Medical History since last exam:
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;; Comments on:
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;;
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;; 1. Hospitalizations and outpatient care from the time between last
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;; rating examination to the present, UNLESS the purpose of this
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;; examination is to ESTABLISH service connection, then the complete
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;; medical history since discharge from military service is required.
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;; 2. Frequency, severity and duration of psychiatric symptoms.
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;; 3. Length of remissions from psychiatric symptoms, to include capacity
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;; for adjustment during periods of remissions.
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;; 4. Treatments including statement on effectiveness and side effects
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;; experienced.
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;; 5. SUBJECTIVE COMPLAINTS: Describe fully.
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;;
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;;C. Psychosocial Adjustment since the last exam
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;;
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;; * legal history (DWIs, arrests, time spent in jail)
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;; * educational accomplishment
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;; * extent of time list from work over the past 12 month period and social
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;; impairment. If employed, identify current occupation and length of time
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;; at this job.
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;; If unemployed, note in COMPLAINTS whether veteran contends it is due to
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;; the effects of a mental disorder. Further indicate following DIAGNOSIS
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;; what factors, and objective findings support or rebut that contention.
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;; * marital and family relationships ( including quality of relationships with
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;; spouse and children)
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;; * degree and quality of social relationships
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;; * activities and leisure pursuits
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;; * problematic substance abuse
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;; * significant medical disorders (resulting pain or disability; current
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;; medications)
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;; * history of violence/assaultiveness
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;; * history of suicide attempts
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;; * summary statement of current psychosocial functional status (performance
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;; in employment or schooling, routine responsibilities of self care,
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;; family role functioning, physical health, social/interpersonal
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;; relationship, recreation/leisure pursuits)
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;;TOF
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;;D. Mental Status Examination
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;;
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;; Conduct a BRIEF mental status examinaton aimed at screening for DSM-IV mental
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;; disorders. Describe and fully explain the existence, frequency and extent of
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;; the following signs and symptoms, or any others present, and relate how they
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;; interfere with employment and social functioning:
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;;
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;; * Impairment of thought process or communication.
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;; * Delusions, hallucinations and their persistence.
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;; * Eye Contact, interaction in session, and inappropriate behavior cited
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;; with examples.
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;; * Suicidal or homicidal thoughts, ideations or plans or intent.
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;; * Ability to maintain minimal personal hygiene and other basic activities
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;; of daily living.
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;; * Orientation to person, place, and time.
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;; * Memory loss, or impairment (both short and long-term).
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;; * Obsessive or ritualistic behavior which interferes with routine activities
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;; and describe any found.
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;; * Rate and flow of speech and note any irrelevant, illogical, or obscure
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;; speech patterns and whether constant or intermittent.
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;; * Panic attacks noting the severity, duration, frequency, and effect on
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;; independent functioning and whether clinically observed or good evidence
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;; of prior clinical or equivalent observation is shown.
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;; * Depression, depressed mood or anxiety.
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;; * Impaired impulse control and its effect on motivation or mood.
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;; * Sleep impairment and describe extent it interferes with daytime activities.
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;; * Other disorders or symptoms and the extent they interfere with activities,
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;; particularly:
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;;
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;; - mood disorders ( especially major depression and dysthymia)
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;; - substance use disorders (especially alcohol use disorders)
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;; - anxiety disorders (especially panic disorder, obsessive-compulsive
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;; disorder, generalized anxiety disorder)
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;; - somatoform disorders
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;; - personality disorders (especially antisocial personality disorder
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;; and borderline personality disorder)
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;;
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