Sample Nursing Essays on Patient Health History with Genogram

BIOGRAPHIC DATA

Name: Paul Martins

Age: 32 years

Birth date: 18th September 1987

Address: 164, Alameda Street – Los Angeles

Birthplace: New Delhi, India.

Gender: Male

Marital status: Single

Race: Indian

Occupation: He is an office administrator at a Fortune 500 Company and a doctorate student at the University of California Berkeley.

PAST HEALTH

History Sources: The patient was the informant in this case, past medical reports also helped.

Reason for Seeking Care: The patient complained of frequent back and joint pains as well as chest pains.

History of current illness: Mr. Paul Martins has never been diagnosed with any lifestyle diseases. The current illness began almost 3 months ago. Initially, it was an occasional back or joint pain, which he mostly dismissed based on the assumption that it was probably related to either his frequent travels or the busy schedules he kept either at his office or in school. More recently however, the back and joint pains had become more frequent and there was an occasional chest pain. Over the last two weeks, the pains had grown in intensity, prompting the need to seek medication.

Past Health

Childhood illness: Paul had no diagnosed chronic illness in childhood and had received all the recommended vaccinations at the right time.

Previous injuries: The patient had a minor accident while in high school, which resulted in chest bruises and a broken hand.

Chronic illnesses: None

Hospitalizations: None

Operations: None

Vaccinations:  All vaccinations up to date. The most recent one was the yellow fever vaccination administered during Paul’s last trip from India in January 2019.

Last examinations: The last full body check was done in January 2018, and he had shown signs of being overweight. The doctor had recommended that he should check his lifestyle and diet.

Allergies:  Is allergic to soy.

Current medications:  None

Family History with Genogram

Paul is the last born in a family of seven children. His father lives with hypertension while one of his aunts from the father’s side suffers from obesity. On the other hand, his mother’s side of the family has a history of obesity. His mother has both obesity and hypertension while his maternal grandmother suffered from hypertension and diabetes and was also obese. The maternal grandfather suffered from diabetes and obesity. One of his sisters is also obese but with no attached lifestyle conditions, while his eldest brother is obese and hypertensive.

Key

Female

Male

With multiple conditions

With single condition

 

Review of Systems

General Health: Prior to the current symptoms, the patient reports to have been in good health with no indications of malaise.

Skin: There have been no notable changes in the skin characteristics for the patient except  a few swellings, assumed to be acne.

Self-care: The patient has a very busy schedule that has left him incapable of engaging in lifestyle improvement activities such as exercise. He mostly spends his time in a sedentary position either at his desk or in class.

Head: The patient does not recall any head injuries and does not feel any pains in the head.

Eyes: No problems with vision.

Ears: No hearing defects or reported/ observed ear infections.

Self-care: The patient mostly uses cotton clothes to clean his ears.

Nose: Has the occasional flu or cold, and had reportedly had sinus problems in childhood.

Self-care: He believes in home treatment and mostly uses ginger, lemon and honey concoctions for flu and/ or irritation.

Mouth and throat: No observable voice changes or throat problems.

Self-care: Brushes teeth three times a day after major meals with medicated toothpaste.

Neck: No reported neck, pain, stiffness, or swelling in the neck.

Respiratory: No health issues linked to the respiratory system reported.

Self-care: None.

Cardiovascular: He occasionally experiences a deep seated chest pain and palpitations.

Peripheral Vascular: No reported peripheral vascular conditions.

Self-care: None.

Gastrointestinal: No reported gastrointestinal problems from the recent times. Has had no vomiting or diarrhea in the past 6 months. He occasionally experiences bloating as a result of reactions to cold weather but has nothing else otherwise. Bowel movements also reported efficient.

Urinary: No noted changes in the urinary processes and feelings in the recent times.

Sexual Health: Paul has a girlfriend with whom he is sexually active. They have not been tested for HIV for the past 2 years though they use protection most of the time.

Musculoskeletal: Paul has a full range of motion with no signs of muscle stiffness. However, he feels a bit of tightness when experiencing joint pains.

Neurologic: Has had no neurological problems in the past.

Endocrine: The patient has been making intentional efforts towards weight reduction in the recent past although his practice is inconsistent due to the busy schedule he has.

Functional Assessment

Self-concept: Paul was formerly an active individual, particularly through his high school athletics team. The move to the U.S reduced his activity levels because he has no team, no friends and no time to be active. However, his job gives him a good opportunity to engage in other activities including drinking and smoking, which he never engaged in before.

Activity exercise: Due to Paul’s engagement at his job and in school, his level of physical activity has reduced significantly. This can also be attributed to the reduced level of routine exercise, which is contrary to what he had been used to in high school. In his current role, he has to really push himself and create time for exercise, a practice that he has not developed yet.

Sleep pattern: Paul is a good sleeper, with regular sleep and wake up times. He gets not less than 7 hours of sleep each night.

Nutrition: He mostly skips breakfast and takes a snack, mostly a fruit around mid-morning. Additionally, he takes quite a heavy lunch, which mostly comprises of junk foods such as burgers and sodas. For dinner, he eats out most of the time, with meats and high carbohydrate foods making the major percentage of the foods.

Alcohol and drugs: The patient smokes and also uses alcohol, a habit he began actively after moving to the U.S.

Interpersonal relationships: From the family, Paul has a strong social support system. However, the family is in India and calling them is at times costly. During such times, he finds his girlfriend and some of his friends and workmates as a strong source of support.

Coping and stress management: Paul considers communication with his family and/ or his girlfriend as a key strategy for de-stressing.

Perception of Health

Paul admits that he probably has not been very active in keeping up with a healthy lifestyle as a result of his day to day schedules. He feels that although he is aware of the risk of diabetes, obesity and hypertension in his family, he had not given it a serious thought or even imagined he could also be affected in spite of his weight.

Head-to-Toe Examination

Skin: The skin is warm to the feel and devoid of any inconsistencies. No reported pains or ulcerations on the skin across the entire body.

Head: No noted asymmetries and with all standard features. No abnormalities in any of the features of the head, no lesions or bruises.

Eyes: Paul has normal eyes with a clear cornea and a brown sclera. There are no signs of cataracts or any other eye problems. All the ocular muscles are 100% functional and the pupil is bilaterally accommodative. His visual acuity is 20/25 for the left eye and slightly better for the right eye.

Ears: Has no reported or observed infections, masses, or lesions. There is good bilateral hearing even for whispered words.

Nose: The nose is symmetric with no unusual lesions or discharge. The skin on the nose is also smooth with minute mole (a birthmark) on the right side of the nose. The midline septum is strong enough with no allergic reactions.

Mouth: The mouth has full dentition; the tongue is centrally placed in the buccal cavity. There are also no ulcerations in the buccal cavity and no inflammations on the tonsils. The patient also reports no tonsil stones.

Spine and back: No deformities or injuries on the spine or the back.

Thorax and lungs: The conditions of the patient’s chest and lungs are satisfactory although the patient is at risk of lung infections. There are good chest expansions with no symptoms of respiratory distress.

Heart: Generally hyperactive.

Abdomen: No notable abnormalities or probable discomfort at the time of examination.

Extremities: All extremities are symmetrical in size and/ or length with no visible abnormalities. No varicose veins or stretch marks noted.

Musculoskeletal: Full range of motion for the patient. Challenges were only reported for the knee joints particularly during cold.

Neurologic: No noted nerve problems across the entire body.

 

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Assessment

The patient was diagnosed with obesity and high blood pressure.

Sufficient knowledge on the health risks associated with his weight.

Paul is willing to engage in greater physical activity to put his weight on check and to help control the escalation of hypertension.