Zachary LaFontaine Shadow health Treatment Plan
Treatment Plan: 16 of 16 (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 Zachary LaFontaine Shadow health Treatment Plan.
| Learner Selection | Model Documentation |
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Diagnosis: Encounter for routine child health examination with abnormal findings Identified as xxx Evidences: Ms. LaFontaine reports that the reason for the visit is a xx Learner Rationale: Dannis reported that he brought her xxx Score: 3 out of 3 |
Diagnosis: Encounter for routine child health examination with abnormal findings Primary: xxx Evidences: Ms. LaFontaine reports that the reason for the visit is a xxx Model Rationale: The xxis the reason for the xx Because Ms. LaFontaine has indicated she has brought Zachary in for his wxxx, the correct xxxis “Encounter for routine child health examination with abnormal findings Zachary LaFontaine Shadow health Treatment Plan.” As a primary care provider, it is critical to properly code the reason for Zachary’s visit so it can be covered by insurance. |
Additional Diagnosis
| Learner Selection | Model Documentation |
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Diagnosis: xxx Evidences: Breasts are not always empty after feeding Drop in weight percentile for age Feeding sessions of insufficient length Less frequent than normal elimination Mother does not perceive enough time to feed Learner Rationale: Zachary’s reduced weight gain suggests he has feeding problems Score: 6 out of 6 |
Diagnosis: xxx Evidences: Breasts are not always empty after feeding Drop in weight percentile for age Feeding sessions of insufficient length Less frequent than normal elimination Mother does not perceive enough time to feed Model Rationale: A delay or reduction in developmentally appropriate weight gain indicates that Zachary has a problem related to feeding, nutrition, or digestion, as does his somewhat infrequent eliminations. Daanis reports that her breasts do not always feel empty after feedings, which could be an indication that Zachary is experiencing mechanical problems with latching or that Daanis cannot express breast milk. However, Daanis also reports that she does not feel like she has enough time to feed Zachary, and describes feeding sessions that are shorter than recommended. Zachary LaFontaine Shadow health Treatment Plan This leads to “Feeding difficulty” being the correct additional diagnosis. Kerzner B et al. (2015). A practical approach to classifying and managing feeding difficulties. Pediatrics, 135(2): 344. |
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: xx Learner Rationale: Vxxx Score: 1 out of 1 |
Recommended: xxx
Zachary may be xxx, which is critical for infant xxx. xx is common in children who are breastfed, as breast milk contains no xx. You will recommend an xxxxto Daanis for Zachary to take Zachary LaFontaine Shadow health Treatment Plan. |
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Non-Pharmacological Intervention
Selected:xx Learner Rationale: Dannis should be dencouraged to create a feeding schedule Score: 1 out of 1 |
Recommended: xxx
You will talk to Daanis about acquiring a breast pump and planning an effective feeding schedule. A more structured feeding schedule and the use of a breast pump will allow Daanis to fully meet Zachary’s nutritional needs while also maintaining her own well being. |
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Educate Guardian
Selected: xxx Learner Rationale: Pediatric care necessitates education Score: 1 out of 1 |
Recommended: xxx
Providing education to patients’ guardians is a key component of pediatric practice. Clearly communicating to guardians what care their children need and why improves adherence and outcomes. |
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Preventive Screening and Intervention
Selected: xx Learner Rationale: The patient is due for several vaccines Score: 1 out of 1 |
Recommended: xx
At two months, Zachary is due for several vaccines: Hepatitis B (HepB), Rotavirus (RV), Diphtheria, Tetanus and Acellular pertussis (DTaP), Pneumococcal conjugate (PCV13), Inactivated poliovirus (IPV), and Haemophilus influenzae (HiB) Zachary LaFontaine Shadow health Treatment Plan. You will talk to Daanis about the need for these vaccines and administer them with her consent. |
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Diagnostic Testing: Labs and Imaging
Selected: No Learner Rationale: No diagnostic tests are required Score: 1 out of 1 |
Recommended: No
As the patient’s diagnosis is evident, no further diagnostic testing is needed. |
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Referral of Care
Selected: xx Learner Rationale: Dannis should consult with a lactation specialist Score: 1 out of 1 |
Recommended: xx
A lactation specialist will allow Daanis to improve her feeding practices and integrate her challenging schedule with Zachary’s nutritional and emotional needs. You will refer Daanis to a lactation specialist that is in network with Indian Health Services. |
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Continued Care and Follow-up
Selected: Yes Learner Rationale: A follow p appointment should be scheduled to check if the interventions are working Score: 1 out of 1 |
Recommended: Yes
Because Zachary is lagging developmentally, it would not be appropriate to wait for his four-month wellness visit to see if the interventions you have selected are working. You will schedule a follow-up appointment with Daanis to make sure that the interventions have resolved Zachary’s feeding problems and that he is gaining weight in a developmentally appropriate way Zachary LaFontaine Shadow health Treatment Plan. |