Zachary LaFontaine Shadow health Treatment Plan
Primary Diagnosis
Check your responses for the Problem Selection tasks. You get one point for each correct diagnosis and evidence linked to it. If there are multiple correct diagnoses, you also get a point for identifying the primary one.
Table of Contents
Student’s Choice Model Notes
Issue: Regular child health check with unusual findings
Identified as xxx
Evidence:
Ms. LaFontaine says the visit reason is xx
Student’s Reasoning:
Dannis mentioned bringing her xxx
Result: 3 out of 3
Issue: Regular child health check with unusual findings
Primary: xxx
Evidence:
Ms. LaFontaine says the visit reason is xxx
Model’s Reasoning:
The xx is why Zachary is here. Since Ms. LaFontaine brought him in for his wxxx, the correct xxx is “Regular child health check with unusual findings.” Properly coding the reason for Zachary’s visit is vital for insurance coverage.
Additional Diagnosis
Student’s Choice Model Notes
Issue: xxx
Evidence:
Breasts not always empty after feeding
Drop in weight percentile for age
Feeding sessions too short
Less frequent eliminations than usual
Mother feels she lacks enough time to feed
Student’s Reasoning:
Zachary’s reduced weight gain hints at feeding issues
Result: 6 out of 6
Issue: xxx
Evidence:
Breasts not always empty after feeding
Drop in weight percentile for age
Feeding sessions too short
Less frequent eliminations than usual
Mother feels she lacks enough time to feed
Model’s Reasoning:
A delay in appropriate weight gain suggests Zachary has feeding, nutrition, or digestion issues, as do his infrequent eliminations. Daanis mentions her breasts not always feeling empty after feeds, which could mean Zachary has trouble latching or Daanis can’t express milk. However, Daanis also feels she lacks time to feed Zachary, with sessions shorter than recommended. Hence, “Feeding difficulty” is 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
7 out of 7
Review your answers for the Plan of Care task. Choose “Yes” or “No” for each of the seven care actions. You’ll get one point for each correct answer.
Student’s Choice Model Notes
Medication
Selected: xx
Student’s Reasoning:
Vxxx
Result: 1 out of 1
Recommended: xxx
Zachary may need xxx, essential for infant xxx. xx is common in breastfed babies since breast milk lacks xx. You’ll suggest an xxxxto Daanis for Zachary.
Non-Medical Intervention
Selected:xx
Student’s Reasoning:
Dannis should create a feeding schedule
Result: 1 out of 1
Recommended: xxx
Discuss acquiring a breast pump and planning a feeding schedule with Daanis. Structured feeding and a breast pump will meet Zachary’s needs and support Daanis.
Educate Guardian
Selected: xxx
Student’s Reasoning:
Pediatric care requires education
Result: 1 out of 1
Recommended: xxx
Educating guardians is crucial in pediatric practice. Clear communication improves adherence and outcomes.
Preventive Screening and Intervention
Selected: xx
Student’s Reasoning:
Zachary needs several vaccines
Result: 1 out of 1
Recommended: xx
At two months, Zachary needs Hepatitis B (HepB), Rotavirus (RV), Diphtheria, Tetanus and Acellular pertussis (DTaP), Pneumococcal conjugate (PCV13), Inactivated poliovirus (IPV), and Haemophilus influenzae (HiB) vaccines. Discuss the necessity with Daanis and administer with consent.
Diagnostic Testing: Labs and Imaging
Selected: No
Student’s Reasoning:
No tests needed
Result: 1 out of 1
Recommended: No
No further testing is needed with an evident diagnosis.
Referral of Care
Selected: xx
Student’s Reasoning:
Dannis should consult a lactation specialist
Result: 1 out of 1
Recommended: xx
A lactation specialist can improve feeding practices and integrate them with Zachary’s needs. Refer Daanis to one under Indian Health Services.
Continued Care and Follow-up
Selected: Yes
Student’s Reasoning:
Follow-up needed to check intervention success
Result: 1 out of 1
Recommended: Yes
Schedule a follow-up with Daanis to ensure Zachary’s feeding issues are resolving and he’s gaining weight as expected.
Zachary LaFontaine Shadow health Treatment Plan
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 |
|
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 |
|
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 |
|
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. |
|
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. |
|
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. |
|
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. |
|
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. |
|
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. |
|
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. |
