The patient is a 28-year-old male veteran of the Iraq war who served two tours of duty. He was referred to a Veterans Affairs Medical Center for evaluation. He experienced combat and survived two improvised-explosive-device (IED) explosions while riding in military vehicles. Four fellow soldier friends were killed in the two vehicle explosions. After returning from Iraq two years ago, the patient began experiencing anxiety-like symptoms, including a pounding heart, sweating, and trouble breathing on occasions. He also reported bad dreams of his war experiences. He had difficulty falling and staying asleep. He also reported 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 admits to having thoughts of and plans for suicide. The patient is diagnosed with chronic posttraumatic stress disorder with suicide ideation. To fully evaluate the patient and begin therapy, the patient is admitted to an inpatient unit. Over the next five days, the patient is treated with supportive psychotherapy and cognitive-behavioral therapy. At the time of discharge, the patient reported feeling better and is scheduled to continue receiving outpatient cognitive-behavioral therapy.
Principal Diagnosis: __________
Secondary Diagnoses: __________
Principal Procedures: __________
Secondary Procedure(s):