NURS 505 Week 1 Comprehensive Health History and Genogram Example

Comprehensive Health History and Three-Generation Genogram of a 49-Year-Old Adult Volunteer

Identifying Data and Source

The volunteer is a 49-year-old married dental hygienist who lives with a spouse and a 16-year-old child in a suburban home. The volunteer is the source of the history, was alert and articulate during a 70-minute interview and appeared reliable, with recall supported by a personal medication list and vaccination record.

Interview Approach

The interview took place at the volunteer's kitchen table after the purpose, the use of the information for a graduate assignment and the removal of identifying details were explained and verbal consent was given. Open questions began each section, such as "Tell me about your health over the past few years," followed by focused questions to fill gaps. The volunteer's written medication list and a vaccination card from the pharmacy confirmed several dates, and two family history details were checked by a phone call to the volunteer's sister, with permission. These steps support the reliability rating above.

Reason for the Visit

The volunteer has no acute concern and agreed to the interview as a general health review, adding, "I'd like to know what I'm due for at my age."

Present Health

The volunteer describes current health as good. The only ongoing symptom is intermittent low back ache after long days of leaning over patients, about twice a week for the past year, rated 3 of 10, relieved by stretching and ibuprofen 400 mg no more than twice weekly, without leg pain, numbness, weakness or bladder or bowel changes.

Past History

Childhood illnesses included chickenpox and frequent ear infections. Adult illnesses include hypothyroidism diagnosed in 2019, treated with levothyroxine, and an episode of kidney stones in 2016 that passed without surgery. Surgical history includes an appendectomy at age 23. There have been no other hospitalizations, injuries or transfusions.

Medications and Allergies

Current medications are levothyroxine 75 mcg each morning on an empty stomach, a daily multivitamin and ibuprofen as described. The volunteer is allergic to penicillin, which caused hives at age 12, and reports no food or latex allergies.

Health Maintenance

Immunizations include a tetanus, diphtheria and pertussis booster in 2018, annual influenza vaccines and COVID-19 vaccination; the volunteer has not received the shingles vaccine. The last dental and eye examinations were within the past year. A colonoscopy at 45 was normal. A lipid panel three years ago was "a little high," and no diabetes screening has been done in the past three years. The volunteer wears a seat belt, has a working smoke detector and stores no firearms at home.

Family History

The family history spans three generations and is shown in the genogram in the Appendix. The volunteer's father, now 76, had a myocardial infarction at 58 and has type 2 diabetes. The mother, 74, has hypothyroidism and was treated for breast cancer at 62. One older brother, 52, has hypertension, and a younger sister, 45, is healthy. The paternal grandfather died at 64 of a stroke and the paternal grandmother at 81 with dementia; the maternal grandfather died at 70 of lung cancer and was a heavy smoker, and the maternal grandmother died at 88 of heart failure. The volunteer's child is healthy.

Personal and Social History

The volunteer completed an associate degree in dental hygiene, has worked in the same practice for 18 years and finds the work satisfying though physically tiring. The volunteer has never smoked or vaped, has wine with dinner on two or three evenings a week and uses no other substances. Exercise consists of walking the dog three evenings a week for about 30 minutes. The diet is described as "mostly home cooking, too much takeout on weekends." Sleep is about six and a half hours a night, with occasional trouble falling asleep during busy weeks. The volunteer attends church most Sundays and describes faith and family as main sources of support. The main stressor is caring from a distance for aging parents in another state.

Functional Status

The volunteer performs all activities of daily living and work duties independently, drives, manages finances and household tasks, and climbs two flights of stairs at work without stopping. The only functional limit is needing to stretch after long procedures because of back stiffness. The volunteer has no hearing or vision limitations that affect work and uses reading glasses for close tasks.

Review of Systems

General: weight stable at about 172 pounds; no fevers, night sweats or fatigue beyond end-of-day tiredness. Skin, hair and nails: winter dryness only; no rashes or changing moles, and hair and nails unchanged. Eyes, ears, nose and throat: reading glasses for two years; no headaches, vision changes, hearing loss, sinus problems or sore throats. Neck: no lumps or stiffness. Respiratory: breathing easy at rest and on stairs, with no cough or wheeze. Cardiovascular: denies chest discomfort, racing heartbeat, ankle swelling or breathlessness when walking the dog uphill, an important negative given the father's early heart attack. Gastrointestinal: no heartburn, change in bowel habits, blood in stool or abdominal pain. Urinary: no frequency, burning or blood; no stone symptoms since 2016. Musculoskeletal: low back ache as described; no joint swelling. Neurologic: no numbness, weakness, seizures or memory concerns. Psychiatric: no depressed mood or anxiety beyond situational stress; sleep as described. Endocrine: temperature tolerance unchanged since the thyroid dose was adjusted; thirst and urination normal. Hematologic: no easy bruising or bleeding.

Summary of Risks and Recommendations

The interview turned up no active disease beyond treated hypothyroidism, but the family history and a few overdue screenings point to clear next steps. The father's myocardial infarction at 58 falls just outside the usual definition of premature coronary disease in a male first-degree relative, which is onset before 55, but together with a previously elevated lipid panel and a brother with hypertension it supports updating cardiovascular risk assessment with a new lipid panel and blood pressure measurement (Bickley et al., 2021). With a father who has type 2 diabetes and a body weight the volunteer believes is above ideal, screening for prediabetes and diabetes is recommended because the Task Force advises it for overweight or obese adults in the 35 to 70 age band (Davidson et al., 2021); weight and body mass index should be measured at the examination. The volunteer is eligible for the recombinant shingles vaccine at 50. The mother's breast cancer at 62 should be recorded and reviewed with a validated family history tool, though one first-degree relative diagnosed after menopause does not by itself indicate genetic testing. The back ache warrants attention to work ergonomics, such as chair height, patient positioning and short stretching breaks between appointments, and the ibuprofen use, though modest, should be reviewed against kidney stone history and hydration. Sleep and caregiver stress are worth revisiting at follow-up, since short nights combined with long-distance caregiving can wear down health in ways the review of systems does not yet show. A short validated sleep questionnaire and a question about support for the parents' care would be reasonable at the next visit.

Appendix: Genogram

The genogram below is presented as a table for accessibility; the submitted version uses standard symbols, with squares for males, circles for females, a slash through deceased members and a key (McGoldrick et al., 2020).

References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Davidson, K. W., Barry, M. J., Mangione, C. M., Cabana, M., Caughey, A. B., Davis, E. M., Donahue, K. E., Doubeni, C. A., Krist, A. H., Kubik, M., Li, L., Ogedegbe, G., Owens, D. K., Pbert, L., Silverstein, M., Stevermer, J., Tseng, C. W., & Wong, J. B. (2021). Screening for prediabetes and type 2 diabetes: US Preventive Services Task Force recommendation statement. JAMA, 326(8), 736-743. https://doi.org/10.1001/jama.2021.12531

McGoldrick, M., Gerson, R., & Petry, S. (2020). Genograms: Assessment and treatment (4th ed.). W. W. Norton.