Name: Juan Llorente.

Age: 18.

Rank: PFC.

Chief Complaint: Patient has been complaining about inability to sleep, and having “crippling nightmares,” once he does finally get to sleep. All vitals are normal. But, BP was high. Lately, patient has been “seeing things that aren’t there,” causing him more distress. After, History and Physical, patient admitted to having been shell-shocked in his last firefight. He may or not have lost time. A possible anteroposterior concussion may have taken place. Patient’s motor responses are fine. But, an unusual eye saccade was present. His commanding officer claimed that it was just the result from a blast of sand from a roadside IED.

Diagnosis: Patient, may possibly be malingering for pain meds. Will keep an eye on him, and slowly distribute his medication as necessary. He was sent home with some Aspirin and a reusable ice pack for his headaches.