Zachary LaFontaine Treatment Plan Shadow health
Diagnosis: Encounter for routine child health examination with abnormal findings
Table of Contents
Identified as primary
Evidences: Ms. LaFontaine reports that the reason for the visit is a well-child exam
Choosing Problems
6 correct out of 9
Main Diagnosis
Check your answers for the Problem Selection tasks. You get one point for every right diagnosis and one point for each correct evidence linked to a correct diagnosis. If there are multiple correct diagnoses, you also earn a point for correctly identifying the primary diagnosis.
Learner’s Choice Model Documentation
Issue: Encounter for regular child health examination with unusual findings
Identified as main
Proofs:
Ms. LaFontaine mentions that the purpose of the visit is a routine child check-up
Learner’s Reasoning:
None provided
Result: 2 correct out of 3
Issue: Encounter for regular child health examination with unusual findings
Main: Yes
Proofs:
Ms. LaFontaine mentions that the purpose of the visit is a routine child check-up
Model’s Reasoning:
The main diagnosis is why the patient is visiting. Since Ms. LaFontaine says she brought Zachary for his regular check-up, the correct main diagnosis is “Encounter for regular child health examination with unusual findings.” Properly coding Zachary’s visit reason is crucial as a primary care provider for insurance coverage.
Additional Issues
Learner’s Choice Model Documentation
Issue: Feeding Challenges
Proofs:
Breasts not always empty after feeding
Zachary falls asleep while breastfeeding
Feeding sessions too short
Mother feels she lacks time to feed
Mother doesn’t consume enough calories
Learner’s Reasoning:
I found Zachary to be a normally developed infant
Result: 4 correct out of 6
Issue: Feeding Challenges
Proofs:
Breasts not always empty after feeding
Drop in weight percentile for age
Feeding sessions too short
Less frequent than normal elimination
Mother feels she lacks time to feed
Model’s Reasoning:
A delay or reduction in the appropriate weight gain indicates Zachary has issues related to feeding, nutrition, or digestion, as do his somewhat infrequent eliminations. Daanis mentions her breasts not always feeling empty after feedings, which could indicate mechanical issues with latching or expressing breast milk. However, Daanis also reports feeling short on time to feed Zachary, with feeding sessions shorter than recommended. Hence, “Feeding Challenges” is the correct additional diagnosis. Reference: Kerzner B et al. (2015). A practical approach to classifying and managing feeding difficulties. Pediatrics, 135(2): 344.
Plan of Action
5 correct out of 7
Review your responses for the Plan of Action task. You must choose “Yes” or “No” for each of the seven care actions. You earn one point for selecting the right answer for each care action.
Learner’s Choice Model Documentation
Medication
Selected: No
Learner’s Reasoning:
No for the baby. However, the mother will need supplements such as multivitamins
Result: 0 correct out of 1
Recommended: Yes
Zachary might lack Vitamin D, vital for infant bone and tooth development. Vitamin D deficiency is common in breastfed children as breast milk lacks Vitamin D. You’ll suggest an OTC Vitamin D supplement for Zachary to Daanis.
Non-Medication Approach
Selected: Yes
Learner’s Reasoning:
Infant nutrition and breastfeeding education.
Result: 1 correct out of 1
Recommended: Yes
You’ll advise Daanis on acquiring a breast pump and devising an effective feeding schedule. A structured feeding schedule and using a breast pump will help Daanis meet Zachary’s nutritional needs and maintain her own well-being.
Educate Caregiver
Selected: Yes
Learner’s Reasoning:
As above
Result: 1 correct out of 1
Recommended: Yes
Educating patients’ caregivers is crucial in pediatric practice. Clearly explaining the care needed for their children improves adherence and outcomes.
Preventive Checks and Action
Selected: No
Learner’s Reasoning:
Not necessary
Result: 0 correct out of 1
Recommended: Yes
At two months, Zachary needs several vaccines: Hepatitis B (HepB), Rotavirus (RV), Diphtheria, Tetanus and Acellular pertussis (DTaP), Pneumococcal conjugate (PCV13), Inactivated poliovirus (IPV), and Haemophilus influenzae (HiB). You’ll discuss these vaccines with Daanis and administer them with her consent.
Diagnostic Testing: Labs and Imaging
Selected: No
Learner’s Reasoning:
Not necessary
Result: 1 correct out of 1
Recommended: No
As the diagnosis is evident, no further tests are needed.
Referral for Care
Selected: Yes
Learner’s Reasoning:
Breastfeeding education, mother’s health, caloric intake, and supplement or vitamin use.
Result: 1 correct out of 1
Recommended: Yes
A lactation specialist can help Daanis improve her feeding practices and manage her challenging schedule alongside Zachary’s nutritional and emotional needs. You’ll refer Daanis to a lactation specialist within the Indian Health Services network.
Continued Care and Follow-up
Selected: Yes
Learner’s Reasoning:
In two months or earlier if necessary.
Result: 1 correct out of 1
Recommended: Yes
As Zachary is lagging in development, waiting for his four-month wellness visit to see if the chosen interventions work wouldn’t be appropriate. You’ll schedule a follow-up with Daanis to ensure the interventions resolve Zachary’s feeding issues and he’s gaining weight as expected for his development.
Zachary LaFontaine Treatment Plan Shadow health
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. |
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. |
