SHADOW HEALTH
DEPRESSION
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, Comprehensive Geriatric Assessment
1. Chief Complaint
1. 86-year-old African American female presenting with:
o Weakness & fatigue (worsening over past month, severe in last 7 days)
o Morning fatigue (occasionally unable to get out of bed)
o Partial relief with rest (improves slightly in afternoon)
o Social withdrawal & guilt (reduced outings, depressed mood)
2. History of Present Illness (HPI)
2. Fatigue Characteristics:
o Timing: Worst in mornings ("like a hangover")
o Alleviating factors: Lying down helps
o No clear triggers identified
3. Depression Screening:
o Moderate depressive symptoms
o Loss of interest in church/social activities (last month)
o Passive suicidal ideation: "It would be okay if I didn’t wake up tomorrow"
o Guilt over appearance & isolation
3. Past Medical History
4. Chronic Conditions:
o Hypothyroidism (dx age 50)
o Type 2 Diabetes Mellitus (dx age 50)
o Depression (dx age 81, worsened after husband’s death)
5. Prior Hospitalization:
o 36 years ago for fatigue/weight loss (DM II & hypothyroidism-related)
4. Medication History
DEPRESSION
[Document subtitle]
[DATE]
[COMPANY NAME]
[Company address]
, Comprehensive Geriatric Assessment
1. Chief Complaint
1. 86-year-old African American female presenting with:
o Weakness & fatigue (worsening over past month, severe in last 7 days)
o Morning fatigue (occasionally unable to get out of bed)
o Partial relief with rest (improves slightly in afternoon)
o Social withdrawal & guilt (reduced outings, depressed mood)
2. History of Present Illness (HPI)
2. Fatigue Characteristics:
o Timing: Worst in mornings ("like a hangover")
o Alleviating factors: Lying down helps
o No clear triggers identified
3. Depression Screening:
o Moderate depressive symptoms
o Loss of interest in church/social activities (last month)
o Passive suicidal ideation: "It would be okay if I didn’t wake up tomorrow"
o Guilt over appearance & isolation
3. Past Medical History
4. Chronic Conditions:
o Hypothyroidism (dx age 50)
o Type 2 Diabetes Mellitus (dx age 50)
o Depression (dx age 81, worsened after husband’s death)
5. Prior Hospitalization:
o 36 years ago for fatigue/weight loss (DM II & hypothyroidism-related)
4. Medication History
