The health history is a very important part of a health care puzzle. Understanding the family history provides information about diseases that are familial.
As you know genograms are important in determining how diseases affect families and are pictorial representations of family relationships and medical histories. As mentioned earlier they are often used to depict common diseases within a family. A genogram allows the user to visualize hereditary patterns and can be useful in identifying repetitive patterns of behavior and to recognize hereditary tendencies.
For this assignment select a patient from your clinical experience whom you are completing a subjective objective assessment and plan (SOAP) note on and complete a genogram based on his or her family history. Write up the family history and create and save a family genogram in the same document.
Here is a case:
chief complaint: back pain
HISTORY OF PRESENT ILLNESS:
Mrs. Chow Joan 65 years old caucasian comes to clinic with complaint of back pain. She said that it has been on going on for the last eight months has been taking ibuprofen 500mg twice a days.
PAST MEDICAL HISTORY:
Lap chole 1987 ; tonsillectomy 45 years ago; right hip replacement 5 years ago;
HOME MEDICATIONS:
lipitor ibuprofen
ALLERGIES: NKDA
FAMILY HISTORY: younger sister died from the stroke when she was 45 years old HTN hyperlipidemia DM type 2 ; older brother died from car accident when he was 60 years old he also have HTN high cholesterol and two mini strokes
SOCIAL HISTORY: smoke 1 pack a day for the last 45 years
REVIEW OF SYSTEMS: difficult to obtain because she is a poor historian
PHYSICAL EXAMINATION:
VITAL SIGNS: T:98.7 P: 68 R 16 BP 112/74 97%ROOM AIR
GENERAL: every thing is within normal limit
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