Shadow Health Depression Latest 2023 Already Passed

Shadow Health Depression Latest 2023 Already Passed Chief 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). 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. Review of Relevant Systems 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 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.