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Shadow Health Depression - Abigail Harris
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Shadow Health Depression - Abigail Harris
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Shadow Health Depression - Abigail HarrisChief Complaint - ✔ Ms. Abigail Harris is an 86-year-old African American woman who presented in the ED with weakness and fatigue.
History of Present Illness - ✔ 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/NKDA
Past Medical History - ✔ 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 - ✔ No previous surgeries.
Medication History - ✔ 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 - ✔ No family history of mental illness.
Social History - ✔ 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).
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