Treatment Plan: 21 of 21 (100.00%)
Primary Diagnosis
Review your answers for the Problem Selection activities. You receive one point for each correct diagnosis, and one point for each correct evidence linked to a correct diagnosis. If there are multiple correct diagnoses, you will also receive a point for correctly selecting which diagnosis is the primary diagnosis.
| Learner Selection | Model Documentation |
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Diagnosis: Pre-Participation Sports Physical Identified as primary Evidences: Samantha reports the reason for her visit is a sports physical Learner Rationale: The patient indicates that she came for a sports physical. Score: 3 out of 3 |
Diagnosis: Pre-Participation Sports Physical Primary: Yes Evidences: Samantha reports the reason for her visit is a sports physical Model Rationale: The primary diagnosis is the reason for the patient’s visit. Because Samantha has indicated she is in the office for her sports physical, the correct primary diagnosis is Pre-Participation Sports Physical. As a primary care provider, it is critical to properly code the reason for Samantha’s visit so it can be covered by insurance. |
Additional Diagnosis
| Learner Selection | Model Documentation |
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Diagnosis: Inappropriate Diet and Eating Habits Evidences: Samantha reports a desire to lose baby fat Samantha reports dizziness Samantha reports wanting to look more athletic Samantha reports skipping lunch once or twice each week Score: 5 out of 5 |
Diagnosis: Inappropriate Diet and Eating Habits Evidences: Samantha reports a desire to lose baby fat Samantha reports dizziness Samantha reports wanting to look more athletic Samantha reports skipping lunch once or twice each week Model Rationale: Samantha’s desire to lose baby fat and appear more athletic, as well as her diet modifications, are clear indications that Samantha’s diagnosis pertains to Inappropriate Diet and Eating Habits. This subjective data, along with Samantha’s normal weight range and healthy BMI collected during physical examination, indicate that Samantha’s problematic behavior is not severe enough to meet the criteria of other eating-related diagnosis or disorders. Therefore, Inappropriate Diet and Eating Habits is the correct additional diagnosis at this time. American Psychiatric Association. (2017). Feeding and Eating Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.dsm10 |
ORDER SHADOW HEALTH, EXAM OR WRITEN PAPER HERE
Review your answers for the Plan of Care activity. You must select “Yes” or “No” for each of the seven care actions. You will receive one point for determining the correct answer for each care action.
| Learner Selection | Model Documentation |
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Pharmacological Intervention
Selected: No Learner Rationale: No disease or problem was indicated by the patient Score: 1 out of 1 |
Recommended: No
This selection is not appropriate. Samantha did not indicate any illness or problem during her sports physical that would require Pharmacological Intervention. |
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Non-Pharmacological Intervention
Selected: Yes Learner Rationale: You should discuss with the patient about her food and dieting habits. Score: 1 out of 1 |
Recommended: Yes
Because you’ve uncovered some eating and body issues during Samantha’s visit, it is appropriate to perform Non-Pharmacological Interventions. You will talk to Samantha and Jackie about their attitudes and habits around food, dieting, and body image in order to interrupt Samantha’s disordered habits before they become more problematic. A more intuitive, holistic approach to healthy living will allow Samantha to shift her focus away from restrictive eating and weight loss towards a lifestyle that supports her well being. |
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Educate Patient
Selected: Yes Learner Rationale: Patient should be taught to take care of her own health. Score: 1 out of 1 |
Recommended: Yes
When a pediatric patient is old enough to take responsibility for their own care, you must educate them as well as their guardian. Clearly communicating to a patient and their guardian what care they need and why improves adherence and outcomes. |
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Preventive Screening and Intervention
Selected: No Learner Rationale: Samantha already got preventive screening during her 134-year old well visit. Score: 1 out of 1 |
Recommended: No
This selection is not appropriate. Samantha already had her 13-year-old well visit where she was vaccinated and screened for preventative care. |
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Diagnostic Testing: Labs and Imaging
Selected: No Learner Rationale: No conditions were indicated that would require testing. Score: 1 out of 1 |
Recommended: No
This selection is not appropriate. Samantha did not indicate any conditions or issues that would require labs or testing. |
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Referral of Care
Selected: No Learner Rationale: This selection is not appropriate. Score: 1 out of 1 |
Recommended: No
This selection is not appropriate. It’s important to follow-up with Samantha about your initial intervention strategies before referring the patient out for specialized care. |
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Continued Care and Follow-up
Selected: Yes Learner Rationale: A follow-up appointment is essential to see how the patient is complying with non-pharmacological interventions Score: 1 out of 1 |
Recommended: Yes
Given Samantha’s inappropriate eating habits and body image concerns, a follow-up appointment to see how well she is adhering to the non-pharmacological interventions is an appropriate selection. |
| Learner Selection | Model Documentation |
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Discuss life-threatening health problems caused by eating disorders, such as heart failure, bone loss, hair and tooth loss, and loss of menses.
Selected: Yes Learner Rationale:
Score: 1 out of 1 |
Recommended: Yes
Given Samantha’s lack of knowledge around the consequences of eating disorders, it is critical she understand the long-term consequences of poor nutrition. Samantha’s diagnosis of Inappropriate Diet and Eating Habits requires that Samantha understand the potential risks she is taking with her behavior. Therefore, Discuss Life-threatening Health Problems is an appropriate selection at this time. |
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Discuss limiting Samantha’s media intake, including unfollowing fitness accounts on social media and refraining from watching shows about weight loss or dieting.
Selected: Yes Learner Rationale:
Score: 1 out of 1 |
Recommended: Yes
Given that Samantha mentioned social media and peer pressure as influencing her body image and self-esteem, it is critical she limits her exposure to media that promotes dieting, weight loss, fitness, and idealized or unrealistic bodies. Samantha’s diagnosis of Inappropriate Diet and Eating Habits requires a holistic approach that considers the cultural factors that may influence her. Therefore, Limiting Media Intake is the appropriate selection at this time. |
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Discuss with Samantha various ways to track her calorie intake, including apps and food diaries, to ensure she meets her recommended caloric intake.
Selected: No Learner Rationale:
Score: 1 out of 1 |
Recommended: No
Given best practices and the details of Samantha’s case, this is an inappropriate intervention. Taking into account all of Samantha’s signs and symptoms, it is not appropriate to encourage Samantha to fixate further on calories or food intake. Eating Disorder Foundation. (n.d.). About eating disorders. https://eatingdisorderfoundation.org/learn-more/about-eating-disorders |
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Educate Samantha on identifying problematic eating behaviors, including skipping meals on purpose, misusing laxatives, counting calories, or purging via exercise or vomiting.
Selected: No Learner Rationale:
Score: 1 out of 1 |
Recommended: No
Given best practices and the details of Samantha’s case, this is an inappropriate intervention; however, Samantha could be educated on problematic eating behaviors, including in-depth examples like misusing laxatives or purging via exercise or vomiting may unintentionally give the patient more strategies to continue covert disordered eating. Eating Disorder Foundation. (n.d.). About eating disorders. https://eatingdisorderfoundation.org/learn-more/about-eating-disorders |
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Increase knowledge of coping mechanisms for low self-esteem and poor body image, including journaling, support groups, relaxation and stress management, positive self-talk, and affirmations.
Selected: Yes Learner Rationale:
Score: 1 out of 1 |
Recommended: Yes
Given Samantha’s poor body image, desire to lose weight, and her tendency to compare herself to her peers, it is critical she develop positive coping mechanisms to build a more neutral, if not positive, approach to her body. Coping mechanisms may include journaling, support group, relaxation and stress management, positive self-talk, and affirmations. Samantha’s diagnosis of Inappropriate Diet and Eating Habits requires a patient-centered empathetic approach. Therefore, Increase Knowledge of Coping Mechanisms is the appropriate selection at this time. |
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Inform Samantha that if she sets her mind to it, she can overcome her body issues and low-self esteem through proper diet and exercise.
Selected: No Learner Rationale:
Score: 1 out of 1 |
Recommended: No
Given best practices and the details of Samantha’s case, this is an inappropriate intervention. Disordered eating arises from complex, overlapping factors such as culture, fatphobia, peer pressure, and anxiety. Informing Samantha that she can simply choose to overcome her low self-esteem is not a patient-centered intervention. Eating Disorder Foundation. (n.d.). About eating disorders. https://eatingdisorderfoundation.org/learn-more/about-eating-disorders |
Education
| Learner Response | Model Response |
| Forcing yourself to diet or skip meals can make you very sick because strong bones teeth, and hair require adequate nutrition. | Eating as much as you should is a very important part of staying healthy. Forcing yourself to diet or skip meals can make you very sick. Strong bones, hair, and teeth all require sufficient nutrition and calories. Eating well is important for development. You mentioned feeling self-conscious about not having your period yet, but you’re developing at a normal rate. Eating regularly will help you stay on track to develop properly, which includes getting your period. Also, you’re a soccer player — that requires a lot of energy and stamina. Eating plenty of food allows you to perform on the field and helps protect you from injury and overexertion. As an athlete, a student, and a young woman, having three meals of balanced food a day will help you achieve your goals. |
| Learner Response | Model Response |
| You should limit media exposure and remember that your body deserves to be fed, cared or, regardless of the size. | Samantha, you mentioned social media and your friends’ follower count as influencing your body-image. We’re going to talk about social media and strategies you can use to protect your mental health and body-image. It’s critical you limit your exposure to media sources that promote diet culture, fad diets, weight loss, fitness goals, and idealized, unrealistic bodies. Instead of focusing on how you look in comparison to others, try to reframe those thoughts and remind yourself that your body isn’t a problem to be solved or punished. When you see images, articles, or TV shows that make you feel bad, turn them off and remember your body deserves to be fed, cared for, and appreciated, regardless of its size. |
| Learner Response | Model Response |
| You can try journalling, relaxation and stress management techniques, and affirmations | Now we’re going to talk about some specific coping strategies you can use to interrupt negative thoughts about yourself and work towards a more neutral, if not positive, approach to your body. You can try journaling, relaxation and stress management techniques, replacing negative self-talk with positive things you like and appreciate about yourself, and affirmations. A good affirmation for you might be, “All bodies deserve to be fed and watered,” or “All bodies deserve care and praise.” You can also consider going to a support group for teens looking to build-up their self-esteem. Body image and disordered eating can significantly impact a person’s anxiety levels and sense of control over their lives. Try using these coping strategies the next time you have anxious, controlling, or restrictive thoughts about your body or food. |