Depression: A Clinical Case Study of a Patient at Hampton VA Hospital

Abstract

Mr. A.J. was admitted in the Hampton VA Hospital and was diagnosed with Major Depression and Suicidal Ideation. He is a 40 year old male Caucasian and a war veteran. He had an abusive past and is in a very depressed state and continually states he wants to end his life.

Chief complaint

Mr. A.J. a 40 year old Caucasian male was admitted to the VA Hospital on September 30, 2008. He was extremely intoxicated and constantly verbalizing his intent to take his own life. He has stopped going to work due to his heavy drinking.

Mental status exam

Physical appearance and behaviors

The patient is a 40 year old, caucasian male though he appears to be older than stated age. His appearance is unkempt and his hygiene has been neglected.

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Mr. A.J. is over weight for someone 71 inches tall. He avoid eye contact with or without communication, When spoken to he does not display any emotion on his face he presents a flat or blunt affect facial expression. There are no distinguishing marks or tattoos on Mr. A.J.'s exposed skin. He also tends to rock his body back and forth when in a conversation. His speech is slow although he can answer the question pointed at him coherently.

Motor ability/behavior

The patient has poor posture, psychomotor agitation, he moves very slowly with an abnormal gait. Mr. A.J. is showing signs & symptoms of delirium tremens. He was very withdrawn during points of the session. He looked agitated and had a repeating statement of not wanting to live anymore rocking back and forward.

Sensory ability

Some of Mr. A.J.'s sensory were abnormal because of the alcohol withdrawal symptoms.