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N262 Health History and Interview Genogram Paper Interviewers Name_Kynesa Myler________ Patient Information: Initials: KAP Age: 52 Occupation: college deans secretary Religion: Christian Country of Birth: USA Date of Admission: 01/19/2012 Admitting Medical Diagnosis: Rheumatoid arthritis Date _01/20/2012_____

Chief Complaint & Reason for Hospitalization: patient complains of intense pain in the joints of the hands, wrists and knees on both sides of the body making job as a secretary very painful and difficult

Patient Problem: P: Palliative, Provocative- pain most intense in the mornings or after periods of inactivity. Patient has tried OTC pain medications Q: R: S: Quality, Quantity- severe and feels inflamed Region, Radiation- in wrists, hands and knees on both sides of body Scale of severity- on a pain scale of 0-10; patient stated 10. Patient is on leave from work because of the pain, doing chores around the house and dressing herself is a hardship

T: Timing- a few months before being diagnosed with rheumatoid arthritis. Pain became increasingly worst and lasts longer, stiffness lasts for about an hour U: Understand Patients Perception- patient thinks disease is getting worse of the problem

Past History: broke left ankle at 5, appendicitis in 1999, car accident in 2004 resulting in broken clavicle and a concussion.

Immunizations: all up to date. Received flu shot last season.

Allergies: patient denies any allergies

Habits: Cigarettes: quit 20 years ago after smoking for 15 years Alcohol: drinks two glasses of wine a week Hard drugs: denies doing hard drugs Coffee, tea or other caffeine (coke): denies drinking coffee but drinks a cup of tea every day Medications (currently taking): Aleve for pain Exercise: worked the treadmill daily but now pain interferes

REVIEW OF PHYSICAL SYSTEMS (ROS): Obtain information from the patient on the systems noted. Questions should include those below, but are not limited to them. General Health: 57 ; 178lbs. Patient admits to fatigue, malaise and limited mobility in the mornings, some difficulty sleeping if pain is intense, denies chills and sweats

Skin: area around joints are swollen, tender and inflamed, denies any petechiae, ecchymosis, lesions, hair loss, brittle hair and nails.

Head: denies pain, dizziness, vertigo, headache, history of injury or loss of consciousness

Eyes: eye burning and itching, had corrective eye surgery 5 years ago for nearsightedness

Ears: patient denies any hearing loss, discharge, pain, irritation or ringing in ear

Nose & Sinuses: patient denies pain, congestion and discharge, excessive sneezing, epistaxis, soreness. Also denies obstructed breathing, injuries and inability to smell

Mouth & Throat: last dental visit was October 2011. Brushes twice a day, flosses at night. Denies toothaches, lesions, and soreness. Has sensitivity to hot and cold foods and dry mouth,

but denies lack of taste, hoarseness, and frequent sore throat

Neck: patient denies any stiffness, pain, limited ROM or masses. No enlarged tender nodes in neck, axilla, or inguinal areas

Breasts: tenderness in left breast. Patient denies any masses, pain, or discharge. Never conducts self-breast examination. Date of last mammogram was December 2011. Date of last physical examination of breasts was November 2011

Chest & Respiratory System: patient has chest pain when taking a breath. Denies wheezing or shortness of breath, hemoptysis, or cough. No history of asthma, bronchitis, or pneumonia. Cannot remember date of last TB skin test and never had a chest x-ray

Cardiovascular System: patient has chest pain when taking a breath. Denies any palpitations, cyanosis, heart murmur, hypertension. History of hypertension in family. Denies coronary heart disease and no history of rheumatic fever. Activity tolerance is appropriate for age.

Peripheral Vascular System: edema in knees and wrists. Denies varicose veins, swelling of arms or legs or intermittent claudication. Also denies thrombophlebitis, and color or temperature changes of upper and lower extremities

Gastrointestinal System: appetite is normal. Denies constipation or diarrhea, or flatulence. Also denies nausea, vomiting, hemorrhoids, hernias, jaundice, or bleeding. Yesterdays food and fluid intake: oatmeal, vegetarian burger, french fries, soup, cheesecake, orange juice, diet iced tea, water.

Genitourinary System: denies bladder or kidney conditions or STDs. Denies hematuria, urgency, frequency, dysuria, incontinence, nocturia, polyuria, or dysmenorrhea. Onset of menses at age 12, normal flow once a month, date of last menstral cycle was 3 years ago. Age of menopause was 49. Date of last Pap smear was November 2011.

Sexual History: had first intercourse at 20. Denies any problems with intercourse. Has had 3 sexual partners. Denies use of birth control.

Musculoskeletal System: pain and stiffness in joints. Denies deformity or gout. Has arthritis and has limited ROM with joints. Denies history of disc disease, fractures, or low back pain.

Central Nervous System: denies loss of consciousness, or clumsiness. Also denies difficulty with balance, weakness, or paralysis. Denies any tremor, neuralgia, paresthesia. No history of emotional disorder or speech articulation.

Endocrine System: denies diabetes, polyuria, polydipsia. Also denies intolerance to heat and cold, or hirsutism. Hematologic System: denies excessive bruising or bleeding, or blood transfusions. Patient is unaware of blood type. Denies any excessive exposure to x-rays or toxic agents.

Social/Cultural System: immediate family is husband of 24 years and two sons ages 23, 21. Both sons are away at college. Patient has worked as a secretary for the Dean of Education at a University. Patient is very spiritual and believes everything happens for a reason, although she worries about not being able to do things for herself anymore. Patient has a solid support group with many siblings, both parents passed away. She and her family are active in searching for treatments and cures to lessen the pain she suffers. Genogram: Answer the following three questions: 1. Does the patients present problem appear related to the family history or individual health habits?

2. What risk factors, if any, are suggested by the patients health habits or the family history? (e.g. smoking or alcoholism in family)

3. What preventive teaching should be included in the nurses care plan for this individual? Insert or attach Genogram: