Genogram

Running head: HEALTH HISTORY 1

Health History

Aimely Novales

Miami Dade College

Benjamin Leon School of Nursing

NUR 3039

Professor Ana Espinosa

October 28th, 2021

HEALTH HISTORY 2

Patient Demographics

N.P is a 23-year-old, white, American-Hispanic male. The patient is 6 feet and one inch

tall and weighs 206 pounds. The patient and his twin sister were born at 34 of gestation. He lives

in Miami, Florida.

Chief Complaint / Present Illness

N.P came today complaining of neck pain. He states, “my neck has been aching a lot

since I was involved in a car accident one week ago.” The patient said that the pain comes

whenever he makes a “solid movement.” On a scale of 0-10, the patient states the pain is a 7. He

said that he had taken Tylenol 500 mg to ease the pain, but it aids for a minimum period. Also,

the patient does not complain of any other symptoms like headache, nausea, and vomiting. Other

than the pain, the patient states he is overall “healthy.”

Past Medical History

Patient N.P has a history of chickenpox, common cold, and otitis media during

childhood. The patient was hospitalized once due to ear tube surgery at three years of age. The

patient denies any current illness. Patient N.P has regular checkups every year and is sexually

active. In 2020 the patient got tested for STI and tested negative. The patient states he tested

positive for COVID-19 for about two months and presented with symptoms of a common cold.

He has already tested negative. The patient claims all his vaccines are up to date, included the

Flu shot this year in September.

Current Health Status

The patient N.P states his general health status is outstanding other than the neck pain since the

automobile accident. He practices soccer as a hobby. There are no physical signs of trauma. His

vital signs are respiratory rate 17, heart rate 64, and blood pressure 134/82.

HEALTH HISTORY 3

Genogram

Key:

N.P (23)

Grandfather (71)

Heart & Renal Failure

Grandmother (65)

Sleep Apnea

Smoker

Aunt (44) Mother (47)

Obesity

Grandmother (81)

Heart Failure Grandfather (67)

Father (59)

Diabetes Mellitus

type I

Uncle (54)

Son (23)

Twin Son (16)

Son (35)

Deceased male

Deceased female

Living male

Living female

HEALTH HISTORY 4

Family History

The patient has a family history of Diabetes Mellitus type I from his father, who is 59

years old. The patient’s mother is 47 years old and agonizes from obesity. His grandmother is 65

years old and suffers from sleep apnea, and smokes three cigarettes a day. The patient’s

grandfather is deceased at 71 years old. He suffered from renal failure and heart failure. In

addition, patient N.P has three brothers with no medical illness, aged as follows: 35 years old, 16

years old, and a twin brother.

Personal & Social History

Patient N.P was born at Mount Sinai in Florida. Both his parents traveled from Cuba

when they were younger. He is currently in a connection and lives with his parents. The patient

works as a supervisor at Amazon. The patient is open to physical threats like falling, back issues,

and objects falling onto him at his job. He finalized high school and is presently applying to Art

School. The patient has regular stressors at work.

Review of Systems

Skin, Hair, and Nails: there is no bruising, rashes, or discolorations of the skin. No hair

loss was reported nor noted. Color is consistent with ethnicity.

Head, Eyes, Ears, Nose, Throat (HEENT): the head is normocephalic with no lesions

or masses noted. Pupils are equal, rounded, and reactant to light and accommodations. No visual

changes were reported and deny the usage of glasses. No difficulties hearing and no complaint of

tinnitus and vertigo. The tympanic membrane is intact upon assessment. The patient can

differentiate between different smells. No septum deviation was noted nor runny nose. The

tongue is pink and symmetrical with no signs of ulcerations. No swollen nodes or missing teeth.

the patient states his gums “sometimes bleed when brushing teeth.”

HEALTH HISTORY 5

Neck: no signs of lumps, goiter, or swollen glands. Pain with movement.

Breast and Axillae: no discharge or pain was recorded. No lumps noted.

Respiratory: lung sounds are clear bilateral. No complaint of shortness of breath.

Cardiovascular: S1 and S2 present, no S3 or S4. The patient denies chest pain,

palpitations, or tightness.

Peripheral vascular: denies numbness, tingling, and swelling. Upon assessment,

extremities are warm to touch.

Gastrointestinal: patient denies a decrease in appetite, heartburn, nausea, and vomiting.

Patient bowel movements are regular, with occasional diarrhea. The patient states no black

stools.

Musculoskeletal: the patient denies pain in joints, swelling, or deformities. The patient

reports neck pain since the automobile accident. He denies weakness, gait, or coordination

problems.

Neurologic: He denies seizures, stroke, or tremors. The patient reports no mood swings

or memory disorders.

Urinary: denies urgency, frequency, or incontinence. No report of discoloration or blood

in the urine.

Male genital system: There are no lumps or lesions present. He denies pain and

discharge. He reports no problem with ejaculation nor erection.

Nutritional Assessment

24-hour diet collection:

Breakfast: fasting

Snack: Ham and cheese sandwich with water

HEALTH HISTORY 6

Lunch: steak, rice, and beans bowl with lettuce, tomatoes, and corn.

Snack: a cup of milk and some crackers

Dinner: HE has meat and whole wheat rice with baked potato, banana, and cucumber.

Patient N.T BMI is 29 for his weight and height. He is overweight, but he is an athletic

fit. In addition, the patient has changed his diet to a more nutritious one high in fruits and fibers.

Nutritional Assessment

24-hour diet collection:

Breakfast: fasting

Snack: Ham and cheese sandwich with water

Lunch: steak, rice, and beans bowl with lettuce, tomatoes, and corn.

Snack: a cup of milk and some crackers

Dinner: meat and whole wheat rice with baked potato, banana, and cucumber.

Patient N.T BMI is 29 for his weight and height he is overweight, but he is muscular fit.

The patient has changed his diet to a more nutritious one high in fruits and fibers.

Risk Factors

Patient N.T has a family history of renal and cardiac failure. As well as diabetes mellitus

type I. The patient has physical hazards at work due to location and work description. The patient

stays away from the grandmother whenever she is smoking.

Health Promotion

The patient is to follow up with PCP regarding neck pain. The patient is adjusting the

number of carbohydrates in his diet to keep sugar levels under control. The patient tries to stay

active and not keep a sedentary lifestyle. The patient drinks 7 cups of water and denies the use of

carbonated drinks. The patient denies the usage of tobacco, alcohol, and recreational/ illicit

HEALTH HISTORY 7

drugs. He wears the seatbelt regularly while inside a car. The patient does not exceed the

exposure to the sun, and when he does, he wears sunblock and long sleeve clothing. The patient

states he makes sure the smoke detectors at home are working.