Chief complaint: weakness, depression and fatigue
History of present illness: Diabetes, hypothyroidism and depression.
Ms. Abigail Harris is an 86-year-old African American woman who presented in the ED with weakness and fatigue.
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.
Underactive thyroid.
Medication: Levothyroxine, Venlafaxine, insuline
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
GENERAL: weight loss, 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.
MUSCULOSKELTAL: Joint pain
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.
Social history: Widowed, husband died 6 years ago.Never smoked, drinks alocohol occassionally. Lives in the home with her son and his wife. Primary caregiver is her son. Patient use to attend church, had a knitting group and use to walk her dog.
