Running head: Genogram Paper 1

Genogram Paper

Kendall Lillie

University of Saint Mary

Genogram Paper

Biographical Data:
Name: JM
Marital Status: single
Birth date: 12/12/1996
Race: Caucasian

CC: “I feel very overwhelmed and exhausted. I am extremely tired during the day but wide
awake at night”
HPI: Symptoms started a few months ago, specially when the fall semester of his junior year
began. “They worsen before a big test or when bills need to be paid.” Netflix and
videogames have seemed to help keep his mind off these stressors. Takes a four-hour nap
everyday after class. States that these symptoms have affected his social life and “well-
being.”
PMH: Childhood illness: Chickenpox at age 3. Myringotomy at age 5. No measles, mumps,
croup, pertussis. No rheumatic fever, scarlet fever, or polio. Received childhood
vaccinations recommended at the time.
Accidents: Patient has never been in an accident.
Chronic illnesses: No chronic illnesses.
Hospitalizations: No hospitalizations that he can remember.
Immunizations: Childhood immunizations up to date. Patient does not remember last
tetanus shot or TB test.
Last Examinations: High school sports physical senior year of high school. Last dental
examination as sophomore in high school; last vision test for driver’s license age 18; has
never had an ECG or chest x-ray study.

Meds & Allergies: Patient is not on any medication but is allergic to ragweed and outside mold.
Family History: JM is the second child of two loving parents. See family genogram on last
page.
Social History: Patient does not have a history of drinking, drugs, or partying.

General Overall Health: Patient stated overall health is “average.” No recent weight change, no
weakness. Very fatigued during the day but not at night. Lack of motivation and focus.
Diet: Diet consists of “somewhat healthy food choices.”
Skin: Skin is consistent with genetic background. No pigmentation, rashes, or lesions. No
history of skin disease. No hair loss or change in texture. No change in nails.
Head & Neck: Has “at least one severe headache every week”; no head injuries, has some
dizziness “when getting up too fast,” no syncope or vertigo. Has an external occipital
protuberance, says “its been there forever.” No pain, limitation of motion, lumps, or swollen
glands on neck.
Eyes: No difficulty with vision or double vision. No eye pain, inflammation, discharge, lesions.
No history of glaucoma or cataracts. Does not wear corrective lenses.
Ears: No hearing loss or difficulty. No current earaches. Had multiple ear infections as a child.
No discharge, tinnitus, or vertigo.
Nose: No discharge; has around 2 colds a year; no sinus pain, nasal obstruction, or epistaxis. Has
seasonal allergies.
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Throat & Mouth: No mouth pain, bleeding gums, toothache, sores or lesions in mouth, no
dysphasia, hoarsens, or sore throat.
Breast: No masses, no discharge, no pain or tenderness upon palpation
Respiratory: No history of lung disease; no chest pain with breathing; no wheezing or shortness
of breath. Treats coughs from the common cold with over-the-counter cough medicine.
Cardiovascular: No chest pain, palpitation, cyanosis, dyspnea with exertion, orthopnea,
paroxysmal nocturnal dyspnea, nocturia, edema. No history of heart murmur, hypertension,
coronary artery disease, or anemia.
Peripheral Vascular: No pain, numbness or tingling, or swelling in legs. No coldness,
discoloration, varicose veins, infections, or ulcers. Legs are equal in length.
Gastrointestinal: Adequate appetite with no recent changes. No food intolerances, heartburn,
indigestions, pain in abdomen, nausea, or vomiting. No history of ulcers, liver or gallbladder
disease, jaundice, appendicitis, or colitis. Bowel movement 1/day, soft, brown; no rectal bleeding
or pain.
Genito-Urinary: No dysuria, frequency, urgency, nocturia, hesitancy, or straining. No pain in
flank, groin, suprapubic region. Urine color yellow; no history of kidney disease.
Neurologic: No history of seizure disorder, stoke, fainting. No weakness, tremor, paralysis,
problems with coordination, difficulty speaking or swallowing. No numbness or tingling.
“Sometimes gets nervous before/during a test.”
Musculoskeletal: No history of arthritis, gout. No joint pain, stiffness, swelling, deformity, or
limitation or motion. No muscle pain or weakness.
Hematologic: No bleeding problems in skin; no excessive bruising. Has never had a blood
transfusion.
Endocrine: No history of diabetes. No increase in hunger, thirst, or urination; no problems with
hot or cold environments, no change in skin or appetite.
Psychiatric: Patient does not have a history of mental illness.

General Survey: Patient appears stated age. He is alert and oriented times four. Body build,
height, and weight are in proportion to age, lifestyle, and health. No physical deformities noted.
Patient has a smooth, steady gait. No use of assistive devices. No involuntary movements.
Patient appears to have full range of motion. Mood and affect are appropriate. Responses are
appropriate. Speech is articulate. Content is appropriate. Patient is speaking native language.
Thoughts are relevant and well organized. Patient appears to be well groomed.

Vital signs:

Height: 5’10”
Weight: 150 lbs
BMI: 21.5

Temperature: 98.6 degrees Fahrenheit (tympanic)

Pulse: 68
Respirations: 12
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BP and apical pulse Supine R: 112/70 L: 110/70 Apical pulse: 58

Sitting R: 114/76 L: 114/74 Apical pulse: 64
Standing R: 112/70 L: 114/72 Apical pulse: 62

Skin: Skin is tan with rosy undertones and consistent with genetic background. No lesions or
tattoos present. Upper and lower extremities are warm and dry bilaterally, hand and feet are
slightly cooler. Skin turgor is less than three seconds.
Head and neck: Skull is normo-cephalic. No infections or infestations noted when inspecting
hair. Smooth and steady movement of temporal mandibular joint. Slight pain and tenderness
upon palpation of maxillary and frontal sinuses. Neck appears symmetrical, no lumps noted.
Slight pain and tenderness upon palpation of preauricular and postauricular lymph nodes.
Increased pain and tenderness upon palpation of occipital lymph node. No pain or tenderness
upon palpation of jugolodigastic, submandibular, submental, superficial cervical chain, deep
cervical chain, posterior cervical chain, and supraclavicular lymph nodes. Trachea is midline
with no lateral deviation. Patient appears to have full range of motion. Cranial nerve eleven, the
spinal accessory nerve, is intact. Thyroid is nonpalpable. Cranial nerve nine, the
glossopharyngeal, and ten, the vagus, are intact.
Eyes: Eyebrows are aligned; hair is evenly distributed. Surface of eyelids are smooth with no
lesions. Eyelid is covering upper third of eyelid, no excessive blinking noted. Eyelashes curve
outward, evenly distributed. Conjunctiva is pink and moist. Cornea is clear with no scratches. Iris
is hazel. Sclera is white with red blood vessels present. Pupils are 5 mm bilaterally, black, round
and symmetrical. Peripheral visual fields are equal to examiner, cranial nerve two, the optic
nerve, is intact. Both pupils respond to direct and consensual light, smooth movements, pupils
converge and constrict on accommodation, smooth and steady gaze. Cranial nerves three, the
oculomotor, four, the trochlear, and six, the abducens, are intact.
Nose: Nose is midline and symmetrical. No nasal flaring, no deviation, cilia present. No pain or
tenderness, no masses, no displacement. Nasal mucosa is pink, no deviation of nasal septum.
Slight occlusion noted. Cranial nerve one, the olfactory nerve, is intact.
Respiratory: Skin color on posterior thorax is consistent with genetic background. Posterior
thorax is symmetrical. Rib slope is at a forty-five-degree angle. No pain or tenderness upon
palpation of posterior thorax. Respiratory excursion of posterior thorax is symmetrical.
Vibrations are felt throughout when palpating for tactile/vocal fremitus on posterior thorax. No
pain or tenderness on palpation of costovertebral angle. Resonance heard throughout when
percussing posterior thorax. Vesicular sounds heard over peripheral lung fields. Bronchovesicular
sounds heard midline. No adventitious sounds heard. Smooth, steady breathing. No cough or
mucous. Skin is consistent with genetic background. Anterior thorax is symmetrical. Rip slope is
at a forty-five-degree angle. AP to transverse diameter is one to two. No pain or tenderness upon
palpation of anterior thorax. Respiratory excursion is symmetrical. Vibrations are felt throughout.
Resonance heard throughout. Tracheal sounds heard over trachea. Bronchovesicular sounds
heard over midline. Vesicular sounds heard over peripheral lung fields. No adventitious sounds
heard.

Self-esteem, Self-Concept: Graduated from Plattsburg High School in 2015. Attended Missouri
Western State University the following fall. Has completed over two years of undergraduate
program in pursuit of Health and Exercise Science Bachelors Degree. Income is not sufficient
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enough to support lifestyle. Does not have a religious preference but does believe in a higher power.
Believes “if you look good, you feel good.”
Activity/Exercise: Walks to class on a daily basis but stopped going to the gym several months ago.
Patient is completely independent. Leisure activities include playing video games, taking naps, and
fishing. Has not had a strenuous exercise pattern since high school.
Sleep/Rest: Patient only gets a few hours of sleep every night. Takes long naps during the day in
response to exhaustion from minimal activity. Over the counter sleep aid, such as melatonin, is
currently used.
Nutrition/Elimination: Patient had a protein bar and a small package of skittles for breakfast.
For lunch he had a bacon cheeseburger and waffle fries. Dinner he consumed turkey, potatoes,
green bean casserole, and a dinner roll. Most days he does not have that large of a dinner but was
celebrating Thanksgiving with friends that night. His usual diet is relatively small in order to
conserve money. He frequently receives groceries from his parents but buys his own food when
he goes out. He prepares a lot of the food he consumes and eats by himself.
Interpersonal Relationships/Resources: Patient is the second child with an older brother and a
sister in law. He “gets along with everyone very well.” Receives support from his parents when
encountered with a problem. Spends a lot of time alone, “probably a couple hours a day.”
Believes the time he spends alone is “extremely pleasurable.”
Coping and Stress Management: Patient is extremely stressed about school and his social life.
He “never has time to do anything fun because of the need to constantly be studying.” He also is
undecided about his career path and future in general. Patient moved out of parent’s house in the
last year and got into a serious relationship several months ago. Methods to relieve stress include
sleeping and playing video games.
Personal Habits: Daily intake of caffeine is high to try to stay awake during the day. Has never
smoked cigarettes. Drinks alcohol very rarely and has never had a drinking problem. No use of
street drugs including marijuana, cocaine, heroin, amphetamines, barbiturates, LSD, or
prescription painkillers. Patient has never been in treatment for drugs or alcohol.
Environmental/Hazards: Lives in an apartment with a friend from high school. The area is
decently safe. Has adequate utilities but refuses to use them because they cost too much money.
Has access to transportation. Is not involved in any community services and does not have
hazards at his workplace or residence. Wears a seatbelt every time he is in a car. Has never been
outside the United States. Has never served in the military.
Intimate Partner Violence: Patient does not currently live with intimate partner but says “things
are great” when she is around. Has never been emotionally or physically abused by partner or
anyone else. Has never been hit, slapped, kicked, pushed, or shoved by partner. Partner has never
forced him to have sex. Patient is never afraid of current partner or any ex-partners.
Occupational Health: Patient is currently unemployed. Has never worked with any health
hazards and does not believe any past jobs have impacted his health.
Perceptions of Own Health: Defines health as, “an overall state of wellbeing.” Views own
health as poor due to the stress he is under and the effects he is seeing. He is very concerned
about his inability to sleep at night and his unhealthy coping mechanisms. He believes that once
he is done with college his stress level with decrease and his general health will improve. His
health goals are to start getting an adequate amount of sleep at night and stop sleeping so much
during the day. His expectations of nurses and physicians are “to help achieve these goals.”

Two nursing diagnoses (with supporting documentation from assessment data)

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Insomnia related to frequent naps as evidence by not being able to sleep at night and
daytime exhaustion.
Decrease in productivity related to conflict about life goals as evidence by lack of
motivation and focus.

Health Promotion:
Health promotion with trouble sleeping at night can include obtaining a sleep history and
previous/current bedtime routines, avoiding negative associations with sleep and the worry of
sleep time loss, and evaluating/eliminating noise during sleep hours.
Health promotion regarding a decrease in productivity can include assessing the client’s level of
anxiety and physical reactions to anxiety, encourage the client to use positive self-talk, and
intervene when possible to remove sources of anxiety.
Health promotion to reduces stress includes identifying what is causing the stress, categorizing
these stressors as modifiable or nonmodifiable, providing information as needed about stress
reduction techniques, and exploring possible therapeutic approaches such as acupuncture and
biofeedback.
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Genogram: