Chief Complaint

Weakness and fatigue

Ms. Abigail Harris is an 86-year-old African American woman who presented in the ED with weakness and fatigue.

History of Present Illness

Ms. Harris presents with weakness and fatigue that have lasted since last month. Reports the timing of fatigue is every morning.

Reports weakness and fatigue for last month, increasing over last 7 days. Ms. Harris is occasionally unable to get out of bed in the morning. The timing of fatigue is every morning. Reports that her fatigue is somewhat alleviated by lying down, and that she has slightly more energy in the afternoon. No known triggers. Reports feeling guilty about appearance and lack of social interaction last two weeks. Reports not leaving her house much. She reports a depression diagnosis, and her current depression screening shows her positive for moderate depressive symptoms.

Allergies

NKA

NKA

Past Medical History

Hypothyroidism Diabetes Depression

Hypothyroidism age 50 DM Type II age 50 Depression age 81 Previous hospitalization (36 years ago) for fatigue and weight loss related to DM II and hypothyroidism

Past Surgical History

Denies           ORDER HERE

No previous surgeries.

Medication History

Insulin Levothyroxine Effexor XR Zolpidem

Insulin aspart: 16 units, SC, TID mealtimes Insulin glargine: 45 units, SC, daily Levothyroxine: 50 mcg, P.O., daily Venlafaxine extended-release (Effexor XR): 150 mg P.O. daily Zolpidem: 5 mg, P.O., PRN at bedtime

Family History

Denies family history of mental illness

No family history of mental illness.

Social History

Retired high school teacher. Widowed. Drinks alcohol occassionally, denies tobacco use. Christian Abigail Harris Depression shadow health Documentation

Occupations: Retired high school English teacher. Marital Status: Widowed; husband died six years ago. Substance Use: Never used tobacco. Drinks one alcoholic beverage less than once a month. Religion: Christian (Non-denominational). Her son is her primary caregiver and helps her manage medications, including refilling and picking up prescriptions and ensuring she is complaint. Ms. Harris reports that her depression started after the loss of her husband. Since then, she has moved in with her son and his family. Previously had organized a knitting group at her church and attended weekly, and walked most evenings for her dog and for exercise and stress management. Abigail Harris Depression shadow health Documentation

Review of Relevant Systems

General: Reports weight loss, sleep problems, and fatigue. HEENT: Dizzy in the morning. MSK: Denies joint pain Neurological: Reports weakness Psychiatric: Reports history of depression.

GENERAL: Lost 9 pounds over the last month. Has some trouble falling asleep and staying asleep. Daytime fatigue, worst in morning, like a “hangover.” HEENT: Dizzy in the morning. Mild presbycusia and presbyopia (corrected with glasses) RESPIRATORY: Reports shortness of breath walking around the house (ex. to the bathroom). Mostly lays in bed at home lately. GASTROINTESTINAL: Positive for anorexia: less desire to eat until later in the day. Still takes regular insulin “TID” (mealtimes). Positive for mild nausea and constipation. Negative for abdominal tenderness. MUSCULOSKELETAL: Negative for joint pain, swelling. NEUROLOGICAL: Weak, nearly fell twice last week. PSYCHOLOGICAL: History of depression and has a prescribed antidepressant medication. Does not endorse sad mood. Lost interest and pleasure associated with church and social activities for the last month. Feels unlike herself most mornings. Says that it would be okay if she didn’t wake up tomorrow morning

Elder Abuse Assessment

Appears to be at no risk for elder abuse

Ms. Harris does not appear to be at risk for elder abuse. Her son is attentive and she spends time with her family. She is not left alone for long periods of time because her daughter-in-law stays at home. She expressed that she felt safe in her home. She does not show signs of physical abuse, but may eventually need more help with managing her depression and ADLs.

Appearance

Ms. Harris appears to be of average weight. Demonstrates indirect eye contact and blank facial expression.

Ms. Harris is an 86-year-old African American woman. She is short for her sex and appears to be of average weight. She displays indirect eye contact and a blank facial expression. Posture is relaxed. When she arrived, her clothing was appropriate to age, season, setting, and occasion. She does not appear to be disheveled. She is clean, bathes regularly, and is well-groomed.

Attitude

Open and cooperative

Ms. Harris appears open and cooperative.

Speech

No issues with articulation, intensity, rate, or flow.

Ms. Harris’s speech complexity is as expected for her education and age. No issues with articulation, flow, rate, or intensity. Ms. Harris is soft-spoken and speaks at an excessively low volume.

Mood and Affect

Stable mood, blungted affect

Ms. Harris’s affect is congruous and appropriate to situation but blunted. Mood is stable.

Thought Process

Relevant, logical, and coherent.

Thought process is relevant, coherent, and logical. Ms Harris’s thoughts follow a normal continuity and she displays no potential disordered behaviors. No rhyming, puns, or clang association observed throughout the course of the interview.

Thought Content

Displays passive suicidal ideation

Ms. Harris displays passive suicidal ideation, mentioning that she would be fine with not waking up at all in the morning. Abigail Harris Depression shadow health Documentation

Perceptual Disturbances

Lucid

Ms. Harris is lucid. She does not experience hallucinations, delusions, or any observable abnormal tendencies of any sort.

Orientation and Level of Consciousness

A&O x 4

A&O x 4

Cognition

Abstract and relevant thinking Abigail Harris Depression shadow health Documentation

Ms. Harris shows abstract and relevant thinking. Her serial 7s test is not accurate, but she is able to comprehend and follow instructions. General knowledge is accurate and both remote and immediate memory are intact. New learning ability is accurate as well, and she iss able to copy the interlocking shapes correctly. Abigail Harris Depression shadow health Documentation

Insight

Full awareness of her situation

Ms. Harris has a full awareness of her depression and situation.

Judgment

Intact Abigail Harris Depression shadow health Documentation

Ms. Harris’s judgement is intact. Her response to the “stamped envelope” scenario is appropriate.