Name: Mr. Victor Chavez Gender: Male
Age: 69 Ethnicity: Hispanic
Education: High School Diploma Income: Social security, retirement, and Medicare
Religious/Spirituality: Practicing Catholic Family: Widowed but is close to his remaining family
Diagnosis: Major Depressive Disorder (MDD) single episode
Chief Complaint
“I am tired and don’t want to go on anymore.”
History of Present Illness
According to pt. daughters, pt. stopped caring for self approximately one week ago. Pt. wife died 6 months ago and he has not “been the same” since. Pt. is actively suicidal but has no plan. Depressed and withdrawn mood has affected pt. ability to care for self and feed self. Pt. states has “no energy to do anything”. Pt. states that nothing makes him feel better and that this feeling is constant.
Past Psychiatric History
No previous psychiatric treatment or hospitalizations. No previous psychiatric medications. No known past suicide attempts or self-harm.
Substance Abuse History
The patient denies a history of tobacco, alcohol or recreational drug use. Pt. daughters confirm.
Family History
Pt. parents deceased over 15 years ago. Both died from natural causes. Has 2 living brothers (ages 65 and 72) and 2 living sisters (ages 63 and 78). His 63-year-old sister has previous suicidal attempts and hospitalizations in psychiatric hospitals for major depressive disorder. No other mental health or substance abuse history in the family.
Social History
Pt. born and raised in Mexico. He immigrated to the U.S. after he graduated high school. Uneventful and stable childhood. Married his wife at the age of 21 and she died when pt. was 68 years of age. Pt. has 2 daughters, 2 sons, and 8 grand-children. He worked in the casino industry his entire life. Retired at the age of 65 and is now collecting social security and retirement. No financial concerns. Pt. is practicing Catholic with a strong faith in a higher power.
Mental Status Exam on Admission
The patient presented to the hospital accompanied by his two daughters. Daughters report the patient has not showered in the last week and is not eating or sleeping regularly. The patient is a 69-year-old English speaking Hispanic male; he is alert and oriented to time, place, person, and situation. Wearing unkempt clothing, hair is not clean or combed, and he exhibits overall poor hygiene. Pt. calm, cooperative and exhibits no unusual behavior. His speech is soft and slow. Depressed affect noted. Upon questioning his mood, the patient stated he felt “sad” and as though he did not want to “continue living”. Active suicidal ideations but no plan. The patient’s daughters state he has access to weapons in the home. No prior suicide attempts. Denies homicidal ideations. Denies being violent. Thought processes are linear. Pt. denies hallucinations or delusions. Short term and long-term memory intact. Pt can recall recent and remote events. Good insight/judgment; the patient states he knows that he needs help/ would mail a letter if he found one on the ground.
Past Medical History
Hypertension onset in mid-50’s
Appendectomy as a child in Mexico
Medications
Lasix 40 mg PO BID
Lisinopril 20 mg PO Daily
Allergies
NKA

This assignment does require scholarly writing.
1. What information is pertinent to you as the nurse?
2. What do you think the problem is?