Patient: K Examiner: Gelsey Jian

Age: 65 Date: 8/29/2019

Gender: M “Patient seems reliable”

Subjective: 65 year old male presents with cc of “worried about finances”.

Allergies: Erythromycin, presents with rash

Meds: Marijuana, once weekly. Fish oil, 800mg daily. Denies any prescription medication use.

PHI: Reports “anxiety over financial status”. K states that symptoms began a month ago after losing his
job. K reports smoking marijuana to alleviate symptoms and states that “it helps a little bit”.

PMH:  Cholecystectomy in 2015. Denies childhood hospitalizations or surgeries. Denies previous

episodes of anxiety.

Family history: No living relatives. Mother died of breast cancer at age 55, father died of prostate cancer
at age 60. Denies any history of anxiety or depression in his immediate family.

Social: Denies history of smoking tobacco. Drinks alcohol once weekly. Smokes marijuana once weekly
for anxiety. Denies use of other illicit substances or recreational drugs.

Environmental: K reports being “unable to exercise weekly”. He does not socialize with friends and
believes that his workplace is very stressful.

ROS: Denies SOB and chest tightness. Denies suicidal thoughts. K states he “does not get enough sleep
every night”.

Objective: General survey: K appears to be his stated age. He is awake, alert, and attentive to
surroundings and is able to respond to questions in a timely manner. Skin is evenly tones with no
discolorations or obvious abrasions or lesions. Facial features are symmetrical and maintain range of
movement. He displays no outward signs of acute stress. Appears within normal height and weight for
his age and ethnicity. All body parts appear equal bilaterally in proper proportion and orientation with
no obvious physical deformities. Posture is straight with no apparent kyphosis. Gait is smooth and
balanced without assistance. Appears to have full range of motion in all joints. Maintains eye contact.
Attire is appropriate for the season and clean. Exhibits signs of good hygiene including groomed hair and
no detectable body odor.

Assessment: Diagnosis 1: Anxiety R/T change in financial status AEB report of “worried about finances”
and report of smoking marijuana to alleviate anxiety

Diagnosis 2: Risk for activity intolerance AEB age exceeding 65 and report of being “unable to exercise
weekly”.