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 ...view middle of the document...
Last examination: 09/17/2015. No new findings
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...