Chief complaint -Annual physical exam

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History of present illness HPI-23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle. Past medical history PHH- none PSH- none Drug history – denies Allergies -none Family history-He has a family history of diabetes, hypertension, and alcoholism. Review of symptoms General-No recent weight gains of losses, fatigue, fever, or chills . Head, ears, eyes, nose, throat – none Neck-none Respiratoru-none Cardiovascular-no chest discomfort or palpitations Gi-none GU-none Integument-history of eczema – not active MS/neuro-no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements Objective data Vital signs-B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6 General-23-year-old male appears well developed and well-nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress HEENT-Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, nasopharynx clear, poor dentition – multiple carries. Lungs-CTA AP

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