Questions and Answers(RATED A)
Chief Complaint - ANSWER-Ms. Abigail Harris is an 86-year-old African American
woman who presented in the ED with weakness and fatigue.
History of Present Illness - ANSWER-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 - ANSWER-NKA/NKDA
Past Medical History - ANSWER-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 - ANSWER-No previous surgeries.
Medication History - ANSWER-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