N435
Virtual Family Health Assessment Project
Winona State University

Family Structure and History:

"Tom" is a 44 year old male with a 42 year old wife and a 13 year old son. Tom, his wife and son are Caucasian, with Tom's parents being first-generation German immigrants. His father died from a CVA at 72, and Tom's only sibling died in a motor vehicle accident. His mother-in-law died at age 64 from ovarian cancer. Tom's mother and father-in-law are retired and in overall good health. His brother-in-law works as a carpenter and has no pressing health concerns. Tom's mother lives in a ground floor apartment of their home, which is built on a farm owned by his father-in-law. There are thus 5 people in Tom's immediate family.

Tom works as a welder in a local manufactory, and his wife is employed by the county as a court stenographer. Tom's 13 year old son attends public school in the 7th grade.

Father (CVA) Mother Father-in-law Mother-in-law (Ov. CA)

Brother (MVA) MAIN "Tom" Wife Brother-in-law AFIB, DM II

Son

"Tom" (Primary Patient) Health Issues Atrial Fibrillation, Diabetes Mellitus type 2, hypertension
Health History
1) Past health history
Childhood Illnesses: recurrent Strep Throat, Chicken Pox
Injury History: Left broken radius (age 13) in hockey game
Chronic Illnesses: Type 2 Diabetes Mellitus, Atrial Fib., Hypertension (controlled)
Hospitalizations: 2010 for tachycardia, diagnosed with new onset Atrial Fibrillation
Operations: Tonsillectomy (1978) Obstetric History: Not Applicable Immunizations: Up to date: Influenza, Tdap, MMR, Hep B and Pneumococcal
Allergies: Sulfa.
Last examination: 09/17/2015. No new findings
Current Medications: Aspirin 81mg per day orally Coumadin 2.5mg Monday, Wednesday,Friday orally Coumadin 5mg Tuesday, Thursday, Saturday and Sunday orally Diltiazem ER 180mg once a day orally Metoporol 50 mg twice a day orally Metformin 500 mg twice a day with meals Ibuprofen 400 mg three times a day orally as needed

2) Present health status:
General health state: Patient relates he feels he is in good health, and reports the onset of no new complaints. Patient appears to be cheerful, interacting with staff and spouse without apparent distress. Currently his weight is 114 kg and he is 174 cm tall. His BMI is 37.7 and is thus classified as obese. Current fasting glucose 149mg/dl. INR 2.5.Current vital signs: Temperature - 36.9, Pulse 82 (irregular), Respirations - 12, Blood Pressure 134/76.
Skin: Skin is intact, no lesions noted. Skin turgor is normal. No abnormal moles (no abnormal shapes or colors).
Hair: Hair is blonde and neatly arranged.
Head: Head is symmetrical with no abnormalities noted.
Eyes: Eyes are bright; pupils are equal, round and react briskly to light. Patient states as of last eye exam his vision was 20/30.
Ears: Small amount of wax noted in ear canal. No hearing loss reported.
Nose/Sinuses: Nasal cavities clear and pink, no discharge noted.
Mouth/throat: Tongue midline, pink. Uvula movement appropriate and free when examined. Tonsils noted, not inflamed or enlarged. Some mild swelling and reddening of gums noted, along with 5 fillings. Patient states that he has not received dental care in well over a year.
Neck: No masses noted, no enlarged lymph nodes noted. No thyroid masses.
Breast: No masses noted.
Axilla: No enlarged nodes noted.
Respiratory system: Lungs are clear to auscultation.
Cardiovascular system: No murmur noted. Heart rate noted to be irregular. Strong peripheral pulses with capillary refill less than 2 seconds.
Peripheral vascular system: Fingers are warm and pink, with no clubbing or cyanosis noted. Good capillary refill time
GI system: Bowel sounds present in all four quadrants. Palpation reveals no masses or tenderness per patient. Last BM was last night, described as normal.
Urinary system: Patient states that he voided normally just prior to assessment. He reports urine was slightly yellow in color with no odor or blood. Per patient, no difficulty with voiding.
Genital system: No abnormalities noted. Denies discharge, painful ejaculation
Sexual health: Reports a monogamous relationship with his spouse and offers no complaints. Patient and spouse are discussing a vasectomy.
Musculoskeletal system. Good strength in both upper and lower extremities with good range of motion in all extremities. Report occasional back pain with heavy lifting, but pain is successfully treated at home with rest and Ibuprofen.
Neurological systems: Alert and oriented. Denies memory or concentration concerns. Intact sensation in all extremities, including feet.
Hematological system: Hemoglobin on last lab results (09/17/2015) is 15.2 g/dl. INR is 2.5.
Endocrine system: Hemoglobin A1C is 7.2% Patient reports 3x/day Accuchecks which reveal a typical reading near 150mg/dl.

3) Functional assessment: Self-esteem: He states that he is happy overall Activity: Reports he has joined a gym, and is working with a trainer twice a week to increase his strength and decrease weight. Sleep/rest: States 7 hours sleep per a night.
Nutrition: Recently implemented a change to a diet rich in vegetables and lean meats. Reports some limited success.
Interpersonal relationships/resources: Reports an active, happy home life with wife and son. Member of a local Ham Radio club, attending weekly meetings.
Spiritual resources: Shares a deep faith with his wife, attending church and Bible Studies weekly.
Stress management: Admits to some stress regarding production quotas in his job as a welder. He has been utilizing stress management techniques from the American Heart Association web site with some success. ("AHA Stress," 2014, p. 1)
Personal habits: Non-smoker, denies or recreational drug use.
Alcohol: Reports "a couple of drinks" in social situations approximately six times per year.
Environment/ hazards: Wears seat belt, has several working smoke detectors in his home. Keeps firearms unloaded and locked in gun safe.
Intimate partner violence: Denies, states he feels safe at home and has had no concerns of violence in his life
Occupational health: Aside from production quota stress, he relates that his work environment is safe, with employer-provided flame retardant clothing/eye protection, adequate ventilation and a culture of safety.
Cultural assessment: Reports he feels it's important to pass on to his son the German Christmas traditions he enjoyed as a child.

4) Perception of health: Tom states he is committed to his recent healthy lifestyle changes. He reports he already feels more healthy and fit, finding that it has become easier to incorporate outdoor activities into his time with his family. He reports that his mood generally good and is happy overall.

5) Health promotion activities:
Tom visits the gym three times a week, and works with a personal trainer twice a week to learn proper and productive strength and endurance training techniques. He also reports a greater focus on his diet, but admits some struggles maintaining his eating goals. He spends time with his family for a dedicated hour each evening, playing a board game, cards or other interactive non-electronic game. On most weekends his family tries to participate in the German tradition of "Volksmarch" (People's walk) for exercise. He also attends weekly Ham Radio club meetings and enjoys interacting with friends there, which helps manage his work stress.

6) Virtual Data Analysis: Strengths: Though Tom is -on the whole- an individual good health, he has some medical conditions that demand his attention. Tom's easily palpable irregularly irregular heart rate clearly show atrial fibrillation. His A1C demonstrates his DM2 requires more control. His current BP demonstrates his hypertension is controlled. Weaknesses: An EKG would allow for a more definitive diagnosis for atrial fibrilation, and Tom's self-reporting may be a weak point with his admitted "cheating" on his food plan. Time will tell if his commitment to a healthier lifestyle holds fast. As well, one blood pressure reading sans other readings tells us only little. A pattern of normal pressure readings would make a much stronger case for "controlled" hypertension. In addition, Tom confesses to occasionally skipping his scheduled draws for his INR. causes an irregular heart rate. Educational needs: Tom would benefit from education regarding the sequelae of poor dental health. He would ideally understand the necessity of compliance with INR monitoring while on Coumadin because of the risk of bleeding. As well, though his improved diet is to be commended, education may be required regarding the ingestion of leafy green vegetables while taking Coumadin. Health promotion needs: Provided he can make his lifestyle changes permanent, Tom is well on the way to becoming fit and healthy. Health promotion teaching should stress that weight loss and tight glucose control can prevent can renal and ocular damage and prevent neuropathy. Dental health promotion is also important, as the American Diabetic Association has noted increased rates of gum disease in diabetic patients. ("Diabetic oral health," 2014, p. 1) Referral and follow-up: Diabetic educator can encourage and provide strategies for proper glucose control. Tom would strongly benefit from dental care. A dietician can provide guidance for a healthy weight loss plan. If Tom and his wife decide to pursue a vasectomy, urology/reproductive health referral is appropriate. Cultural Strengths: Tom has stated that he wants to pass on his German heritage. He has cleverly incorporated a traditional German form of exercise (Volkmarch) into the expression of his heritage. Spiritual Strengths: The devotion to his faith and the strength that he draws from that faith can serve to strengthen Tom's coping skills and bond with his family, decreasing stress.
Analysis Justification: Tom's 7.2% hemoglobin A1C and 149mg/dl fasting glucose put him in a category where complications such as heart disease, Alzheimer's Disease, and damage to nerves, kidneys, and hearing are real possibilities. (Mayo Clinic, 2015) However, these results demonstrate that Tom is very close to achieving the control over his disease process he will need to live a healthy life. Tom states that he is committed to a healthier lifestyle so he can "be around for his boy," and agrees to meet with the Diabetic educator and Dietician within the next month. Barring any occult noncompliance, a decrease in caloric intake and an increase in physical exercise will function to decrease Tom's BMI. This will positively affect his diabetes and help to stave off that disease process. Though his atrial fibrillation seems well-controlled with medication, should that change he may seek advice regarding ablation procedures. References
Jarvis, C (2016) Physical Examination & Health Assessment. (7th edition). St. Louis, MO: Elsevier-Saunders.
Four ways to deal with stress. (2014). Retrieved from http://www.heart.org/HEARTORG/GettingHealthy/StressManagement/FourWaystoDealWithStress/Four-Ways-to-Deal-with-Stress_UCM_307996_Article.jsp#.VkveOr8c7IU

Type 2 Diabetes.(n.d.). Retrieved from Mayo Clinic disease and conditions web site: http://www.mayoclinic.org/diseases-conditions/type-2-diabetes/basics/definition/con- 20031902
Diabetics and Oral Health Problems. (2014). Retrieved from http://www.diabetes.org/living-with-diabetes/treatment-and-care/oral-health-and-hygiene/diabetes-and-oral-health.html