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Comprehensive History with Genogram and Physical Exam with Write-Up
NURS 362 Health Assessment for RNs
University of Maryland University College
Spring 2021
March 3, 2021
Health history
, 2
Comprehensive History with genogram and physical exam with write-up
Ms. Tina Jones is a 28 years old African American woman who present to shadow health
hospital for a pre-employment physical exam. She is starting a new job as an accounting clerk at
Smith, Stewart, Silver & Company. She is required to have a physical exam for her health
insurance.
Ms. Jones is alert and oriented to person, place and time. She is the primary source of
information. Her speech is clear, her mood is appropriated. She is sitting upright on the
examination table. She maintaining eye contact during the interview. Her appearance appears
clean with well hygiene. She looks well nourished. Ms. Jones was last hospitalized in Shadow
General Hospital six months ago for a pain and wound in the right foot including fever and
nausea. Her past medical history includes asthma that started when she was 2½ years old,
diabetes type II at age 24, hypertension which she was diagnose six months ago during her last
hospitalization and polycystic ovarian syndrome four months ago during her OB visit. She was
last hospitalized for asthma in high school. Her hypertension was controlled by diet and exercise.
She checks her blood sugar daily at home with an average reading of 90. She has no past surgical
history. Her last dental visit was five months ago and eye doctor visit 2 months ago.
Ms. Jones is allergic to cats. She states that she tries to avoid cats but when she is around them
her asthma “acts up” and she feels tightness in her chest and wheezing. Ms. Jones is also allergic
to Penicillin she gets a rash like hives after taking penicillin. Also, dust exacerbate Ms. Jones
asthma. She states she has problems with dust in the past but it has not happened in a while. Ms.
Jones denies any food or latex allergies.
Ms. Jones diabetes is being treated with metformin 850 mg twice a day. She has changed her diet
to help with her diabetes. She reports losing 10 pounds in the last 4 months. She limits her
carbohydrates intake and avoids sugar. She is excising more now taking walks 4 to 5 times a
Comprehensive History with Genogram and Physical Exam with Write-Up
NURS 362 Health Assessment for RNs
University of Maryland University College
Spring 2021
March 3, 2021
Health history
, 2
Comprehensive History with genogram and physical exam with write-up
Ms. Tina Jones is a 28 years old African American woman who present to shadow health
hospital for a pre-employment physical exam. She is starting a new job as an accounting clerk at
Smith, Stewart, Silver & Company. She is required to have a physical exam for her health
insurance.
Ms. Jones is alert and oriented to person, place and time. She is the primary source of
information. Her speech is clear, her mood is appropriated. She is sitting upright on the
examination table. She maintaining eye contact during the interview. Her appearance appears
clean with well hygiene. She looks well nourished. Ms. Jones was last hospitalized in Shadow
General Hospital six months ago for a pain and wound in the right foot including fever and
nausea. Her past medical history includes asthma that started when she was 2½ years old,
diabetes type II at age 24, hypertension which she was diagnose six months ago during her last
hospitalization and polycystic ovarian syndrome four months ago during her OB visit. She was
last hospitalized for asthma in high school. Her hypertension was controlled by diet and exercise.
She checks her blood sugar daily at home with an average reading of 90. She has no past surgical
history. Her last dental visit was five months ago and eye doctor visit 2 months ago.
Ms. Jones is allergic to cats. She states that she tries to avoid cats but when she is around them
her asthma “acts up” and she feels tightness in her chest and wheezing. Ms. Jones is also allergic
to Penicillin she gets a rash like hives after taking penicillin. Also, dust exacerbate Ms. Jones
asthma. She states she has problems with dust in the past but it has not happened in a while. Ms.
Jones denies any food or latex allergies.
Ms. Jones diabetes is being treated with metformin 850 mg twice a day. She has changed her diet
to help with her diabetes. She reports losing 10 pounds in the last 4 months. She limits her
carbohydrates intake and avoids sugar. She is excising more now taking walks 4 to 5 times a
