Zachary LaFontaine Treatment Plan Shadow health

Problem Selection

6 out of 9

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
Diagnosis: Encounter for routine child health examination with abnormal findings Identified as primary Evidences: Ms. LaFontaine reports that the reason for the visit is a well-child exam Learner Rationale: nothing Score: 2 out of 3	Diagnosis: Encounter for routine child health examination with abnormal findings Primary: Yes Evidences: Ms. LaFontaine reports that the reason for the visit is a well-child exam Model Rationale: The primary diagnosis is the reason for the patient’s visit. Because Ms. LaFontaine has indicated she has brought Zachary in for his well-child exam, the correct primary diagnosis is “Encounter for routine child health examination with abnormal findings.” 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
Diagnosis: Feeding Difficulty Evidences: Breasts are not always empty after feeding Falling asleep while breastfeeding Feeding sessions of insufficient length Mother does not perceive enough time to feed Mother does not consume enough calories Learner Rationale: I really found a normal developed infant Score: 4 out of 6	Diagnosis: Feeding Difficulty 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. 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.

Plan of Care

5 out of 7

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
Pharmacological Intervention Selected: No Learner Rationale: No for the infant. In the other hand, the mother will need suplements such as multivitamis Score: 0 out of 1	Recommended: Yes Zachary may be deficient in Vitamin D, which is critical for infant bone and tooth development. Vitamin D deficiency is common in children who are breastfed, as breast milk contains no Vitamin D. You will recommend an OTC Vitamin D supplement to Daanis for Zachary to take.
Non-Pharmacological Intervention Selected: Yes Learner Rationale: Infant nutrition, and breast feeding education. Score: 1 out of 1	Recommended: Yes 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.
Educate Guardian Selected: Yes Learner Rationale: as above Score: 1 out of 1	Recommended: Yes 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.
Preventive Screening and Intervention Selected: No Learner Rationale: not need it Score: 0 out of 1	Recommended: Yes 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). You will talk to Daanis about the need for these vaccines and administer them with her consent.
Diagnostic Testing: Labs and Imaging Selected: No Learner Rationale: not need it Score: 1 out of 1	Recommended: No As the patient’s diagnosis is evident, no further diagnostic testing is needed.
Referral of Care Selected: Yes Learner Rationale: Breastfeeding education. Mother health, caloric intake, supplements or vitamis use. Score: 1 out of 1	Recommended: Yes 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.
Continued Care and Follow-up Selected: Yes Learner Rationale: in 2 months of before if needed. 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.