Running head: COMPREHENSIVE HEALT HISTORY AND GENOGRAM ASSIGNMENT 1

Comprehensive Heath History and Genogram Assignment

Vanessa Grant

University of Bridgeport
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Comprehensive Heath History and Genogram Assignment

The following paper contains two activities: performing Comprehensive Health History

and the interviewee’s genogram. Comprehensive Health History (CHH) can be helpful

recollecting important information, often times overlooked or unnoticed in the medical history.

The reason this information goes bypassed, is usually due to lack of thoroughness when

examining and/or inquiring the patient. The latter can have negative repercussions in terms of

patient care such as erroneous medications or even the patient’s decease, which is why

performing a comprehensive health history is not only complementary to the medical history but

necessary for his/her assessment (Jarvis,2016). The aim of CHH is making the patient able to

open up about his/her health situations, for instance, letting the nurse know about conditions that

might have affected him/her in the past or at the moment. From the information contained in the

CHH, professionals can develop a plan to orient the patient’s care or treatment.

Drawing a genogram means to represent the patient’s family tree with an illustration

containing details of each member’s health history; some of the data includes dates of birth,

death, cause of death, marital status, among others. There are representations for each member of

the family (and how they are linked to each other), as well as the conditions each of them might

have had. This serves to consider which conditions, diseases or any other hereditary, psychologic

or social aspects can influence and/or influence the patient’s health (Jarvis, 2016); genograms

contribute to create a thorough depiction of the patient’s family history.

Combining the comprehensive health history and the genogram, as well as further

inquiries to the patient and his/her family history might be useful for nurses, so they can carry

important information to physicians or another health professionals; the latter considering that,

often times, nurses act as intermediaries between them and the patients.
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Biographical Data/Present Health

For this case, the patient, known as T. S. is a Canadian interior designer who resides in

New London, Connecticut, she is 52 years old Asian woman. T. S. is originally from Cambodia,

she was born on November 4th 1967 in a small village near the city of Ta Khmao, in the Kandal

province; her parents were victims of the communist regime of the Khmer Rouge in the mid-70s

when she was seven years old. First, her father, a school teacher was abducted by the guerrilla

group, and summarily executed. T. S. managed to flee with her mother and her older brother to

the Northern province, first at her grandmother’s house, later on a refugee camp in Vietnam.

T. S. spent three years on the refugee camp; her mother died from dysentery after six

months they entered to the facility, and her older brother decided to join a resistance group to

fight the government; he became stranded since then. She was adopted by a Canadian marriage

of volunteers (a doctor and a nurse) not long after her mother died; they returned to Canada by

the end of 1978 and they settled in Quebec City, Quebec. By the time they returned to Canada,

she quickly learned French and English; she says she does not remember her native language,

since “she has not spoken a single word of it, by the time she was a little girl”.

By the time she was 18 years old she started her studies in Toronto, she obtained a

Bachelor in Arts. After graduation, she moved with her college boyfriend, an electrical engineer

and relocated in Quebec; they had their first child when T. S. was 21 years old. The couple

remained together for 20 years, until their separation in the late 2000s. When her son finished

college, T. S. decided to go the United States to work, among other trades, as an art history

teacher, curator, and gallerist; first she landed in Vermont, then she went to New York, where

she met her current partner, whom she married, and then they moved to Connecticut in 2012.

The couple decided to adopt a child survivor from the 2011 Japanese Tsunami and Earthquake.
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Both of her parents are still alive and reside in Quebec, they are retirees; her son lives in

Canada and works with Proctor & Gamble. Her first partner died of cancer two years ago. T. S.

says she did not have any news from the remaining members of her maternal or paternal family

in Cambodia, and she did not have any interest in looking for them, especially because she barely

remembers events from those times, admittedly, traumatic for her.

The contact with T. S. was through a client of hers who happens to be one of her closest

friends since she came to Connecticut and, at the same time, a good friend of mine; I have met

her before (although we were not as close as with my other friend), due to her work as a

decorator and interior designer, in fact, she made some arrangements for the house I moved in

when I got married. She was happy to collaborate with the interview, although she regrets not

having enough information from her younger years.

Her appearance is one from a healthy person, at first sight, she looks at least ten years

younger than her age. Her speech is clear and fluent; her tone is soft and even. T. S. has a good

composure, sitting straight with her hands over thighs. She was attentive all the time and provide

clear and concise answers, likewise when she was asked if she needed any clarification or

explanation to the questions she responded she understood all of them; all the content of the

interview was explained to her as well as each of her answers I took notes from, she agreed to

share that information for this paper’s purposes.

T. S. says she is a “sufficient individual”, a very active person both as a foster mom and

as a professional; she keeps a daily schedule of activities and she managed to handle them very

well. She claims her good health is due to her vegan diet and yoga. She says she rarely has health

problems and she think she is a happy person. A month ago, she experienced high fever, sore

throat, difficulties when breathing and a cold, she got tested for COVID-19 with negative results.
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When she was thirteen years old, she had an appendix surgery due to critical case of

appendicitis. Likewise, she had her tonsils removed during that period of time. In their late teens,

T. S. suffer a traffic accident when she was hit by a van, causing her fractures on her left tibia

and fibula; her recovery was successful, with little visible scars. Three years ago, she lost the tip

of her little finger from her left hand from an accident at her home.

She does have several allergies: dust, coffee, lactose, gluten and canola oil; all of them

discovered at a young age. Her blood pressure levels are normal (120/80), she undergoes to

blood and urine tests every six months to check her health, her latest exams (from February this

year) showed results within the normal frame for her age in cholesterol, sugar, triglycerides,

among others. T. S. has never eaten meat, and stop consuming or using any foods or products

from animal origin since she was 18 years old. She has never drunk alcohol or smoked, although

she admits there was a brief period in her life in which she consumed antidepressants for anxiety,

by the time she and her first partner separated.

Medication Reconciliation

T. S. is not taking any medication at the moment. Recently she took acetaminophen to

reduce her flu. The patient admits that prolonged use of acetaminophen causes her nosebleed. T.

S. says she has not been submitted to prescribed medication for a long period of time so far, and

she would not like to rely on “pills” for the most part. She relies her self-care on herbal

beverages, alternative medicine and diet and her daily yoga routine as well as bicycle riding; she

was an avid swimmer for many years. T. S. does not oppose traditional medicine, but she “tries

to avoid it as much as she can”. When she had her child, she discovered she was allergic to

dipyrone.
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Although, as it was mentioned before, she is not taking regular medications, the patient

was instructed in terms of taking the recommended doses in case she gets any prescriptions. In

addition, some of the recommendations made was to be aware of the side effects any prescribed

medications may have on her, and, once she was aware of a possible negative effect, she should

contact her doctor immediately to revise her dosage.

Past Personal Health History/ Family History

T. S.’s does not recall having any particular disease during her childhood, besides

suffering from dehydration and malaria during her stay in the refugee camp. Her sleep is about

six and a half hours a day. As it was mentioned before, the interviewee suffered several

accidents; some during her adolescence some more recent; she only suffered two fractures and a

partial amputation of one of her fingers. Her most visible scars are on her left leg where she

suffered fibula and tibia fractures, as well as the tip of her left small finger is cut off. She also has

a scar from the C-Section of her childbirth; this procedure was necessary because, in her own

words “decided not to go through the pain of labor”.

She has not suffered nervous breakdowns or any psychological disorder. Although T. S.

is slender, she has not suffered any eating disorder; her weight did not increase excessively while

she was pregnant. Her height is 5’5’’ and her current weight is 128 pounds,. Her pregnancy was

a normal (40-weeks) with a healthy baby as a result. Her latest meeting with her gynecologist

shows her in a healthy state with no presence of cancerous cells in her reproductive system or

breasts. She admits she had a very late menstruation (when she was 15), but at the same time it

disappeared very early, when she was 40. For now, she claims she has not suffered any

considerable effects of menopause on her body; she claims she has an active sex life with her

husband, although she has never used any kind of contraceptives.

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T. S. does not recall much of her ancestors on any side. Her mother was an only child and

her paternal grandparents had passed away for as long as she can remember; she assumes her

maternal grandmother died, not long after they went to the refugee camp. She does not know if

her biological father had any siblings, but she cannot remember being “at a family reunion” or

something similar when she was young. Her biological mother was a housewife and a sewer. Her

older brother was 12 years older than her; she does not know if he is still alive. Her foster parents

live together in Canada, both of them in their mid-70s; her adoptive father is on a wheelchair

because of arthritis and he is diabetic, while her mother reports having sleeping problems

Review of Systems

T.S. body mass index (BMI) is 19.5 (considered normal). She remembers always being

thin, however her figure looks athletic for her age. She has smooth skin with an amber tonality.

Her muscles are tonified, people might think she was a gymnast. She wears tight jeans, tank tops

or t-shirts; does not use heels, make up or nail polish; she does not dye her hair either, she cuts it

herself with a pair of scissors. She uses natural concoctions to put on her face and arms instead

of sunscreen, and always carries an umbrella and sunglasses. She does not report any weakness

on her muscles, bones or teeth. Due to skin sensitivity she does not depilate herself.

Her hair is raven black with no grey visible, her eyebrows are normal size as well as her

head. Although T. S. she does not recall suffering any head injuries from her accident, nor report

suffering any headaches or sleeping problems. She only uses glasses for aesthetic purposes (only

the frame, without the lens); her sight is normal according to her latest examination in 2019. The

interviewee reports she has good hearing (no episodes of tinnitus, or vertigo). The interviewee

does not remember having any skin problems (besides the ones caused by her allergies) or lumps

on her body.
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Functional Assessment

T. S. lives with her husband (who is a retired policeman) and adoptive daughter; she

keeps a very active social life, especially with her clients; many of them come at her house or she

visits them; she goes to Canada for holidays to visit her son and her parents. T. S. likes cooking,

and buys products from organic stores. T. S. does not consume sugar or salt, instead, she prefers

using natural spices or fresh-squeezed fruit juices to provide sweet or salt flavors in her food;

recently she discovered organic panela (a derived from whole sugarcane) as a sweetener. Her

beverages include a variety of teas and fruit juices and water. Besides working as an interior

designer, she enjoys being a mother, a housewife and a teacher for her daughter, especially

during confinement. Some of her hobbies are knitting and meditation, although she is not

religious. She likes animals, but does not own any pets because of his daughter’s allergy to fur.

Her diet is strictly vegan, likewise, her husband and daughter do not eat meat either.

T. S. has contact with her family in Canada (her son and foster parents), mostly through

email or phone; she says they call each other at least three times a month to check how they are

doing. She lost contact with her firs partner after her divorce, and she knew about his passing

because of her son. She is in good terms with her current husband’s family, but she rarely

contacts them. Even though her early years were traumatic because of the Cambodian armed

conflict, T. S. does not recall experiencing depression or some sort of PTSD, in her own words

“the more time passes by, the more she forgets about those years”. She does not define herself as

solitary or gregarian; she enjoys spending time with her family, especially her daughter, but she

is not bothered by being around large groups of people. She uses a mobile phone and a computer,

but she does not “rely extremely on them”. Her family income comes from her work and her

husband’s pension; she is saving for her daughter’s future education since she was adopted.
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Genogram

Conclusion

After the interview was concluded, I was aware of how important it is to know your

patient’s history both in personal terms as in health terms. Not too often patients reveal such

intimate details that might contribute in their assessment and treatment if it is necessary. While

CHH condenses the patient’s life span, the genogram synthesizes it with an image. Nurses can

take advantage of these two powerful tools to develop a deeper bond with the patient and

understanding his/her life in a broader sense; beyond just referring the patient’s conditions or

symptoms. Once the information is recollected, nurses can be more assertive on addressing the

patient’s problems, considering their heritage background as well as other psychosocial factors.
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References

Jarvis, Carolyn. (2016). Health Assessment for Physical Examination and Health

Assessment. 7th Edition. St. Louis, MO: Elsevier Publications.

Complete Health History: T.S. [Interview by V. G., Student]. (2020, September).