Musculoskeletal Shoshanna Tillman Follow Up Sick Visit Shadow Health Treatment Plan
Musculoskeletal Shoshanna Tillman Follow Up Sick Visit Shadow Health Treatment Plan
Treatment Plan: 25 of 25 (100.00%)
Problem Selection
9 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: Joint pain
Identified as primary
Evidences:
Bilateral pain
Pain not associated with trauma
Tenderness with palpation
Learner Rationale:
The patient complains of joint and body pain
Score: 5 out of 5
Diagnosis: Joint pain
Primary: Yes
Evidences:
Bilateral pain
Pain not associated with trauma
Tenderness with palpation
Model Rationale:
At this point in the diagnostic process, you can only provide Mrs. Tillman with preliminary diagnoses. In order to determine a definitive diagnosis, more diagnostic testing is required. In primary care, it is common to have multiple concerns in one visit. These two diagnoses may be related or are two unrelated situations, nonetheless, each diagnosis requires individual diagnostic investigation. Mrs. Tillman’s primary diagnosis is joint pain, while her secondary diagnosis is fatigue. The preliminary diagnosis of joint pain is supported by the evidence collected in the physical exam and reported by Mrs. Tillman: tenderness with palpation, pain not associated with trauma, and bilateral pain Musculoskeletal Shoshanna Tillman Follow Up Sick Visit Shadow Health Treatment Plan. The secondary diagnosis of fatigue is supported by the evidence reported by Mrs. Tillman: an unusual lack of energy, feeling tired, and having difficulty completing tasks due to feeling tired. When making a disease diagnosis, it is important to note that disease diagnosis documentation is permanent in the patient’s records and cannot be undone. Therefore, if you do not have the evidence and diagnostic testing to support a disease diagnosis it is best to collect more data before determining a definitive diagnosis, even if the patient’s signs and symptoms point to a likely disease.
Additional Diagnosis
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Learner Selection
Model Documentation
Diagnosis: Fatigue
Evidences:
Difficulty completing tasks due to feeling tired
Feeling tired
Unusual lack of energy
Learner Rationale:
Patient complains of fatigue, geneal stress, sadness and anxiety.
Score: 4 out of 4
Diagnosis: Fatigue
Evidences:
Difficulty completing tasks due to feeling tired
Feeling tired
Education & Empathy : 4 of 4 (100.0%)
During the patient interview, there are a number of opportunities to provide patient education and empathy. The opportunities listed below are those identified by nursing experts to be of particular importance to this patient. A Model Statement is provided as an example of an appropriate response to each opportunity.
Opportunities marked as Not Encountered are opportunities that were not elicited in the interview
Opportunities marked as Not Followed Up are missed opportunities that were present in the interview, but where no statements were made Musculoskeletal Shoshanna Tillman Follow Up Sick Visit Shadow Health Treatment Plan
Opportunities marked as Followed Up were followed up by students, and include the dialogue between student and patient
1 Caffeine
Followed Up
Description: Mrs. Tillman has been drinking large quantities of coffee to make up for her low energy.
Do you take caffeine?
Question
12:58 PM EDT
I do. I’ll have somewhere between 2 to 3 cups of coffee in the morning, then another one or two in the afternoon.
OK, but too much caffeine is not good for your health
Educate
12:58 PM EDT
Ah, OK.
Model Statement: “I know that you have been feeling very tired and that the coffee helps give you energy bursts, but the caffeine may also be contributing to your ongoing fatigue. Decreasing your coffee intake a little bit can help curb those energy dips.”
2 Exercise
Followed Up
Description: Mrs. Tillman has been feeling very fatigued and reports not having a lot of time or energy to exercise, but movement like walking has helped her pain and stiffness.
Do you exercise?
Question
12:58 PM EDT
I probably could be exercising more. I just don’t have a lot of time or energy. I’ll walk the dog 3 or 4 times a week, which is something. But I used to do these yoga classes, and spin classes, but those don’t really make sense for me now.
I understand your concern but you should always exercise
Educate
01:00 PM EDT
Ah, I see.
Model Statement: “I know that finding the time and the energy to exercise is difficult given your exhaustion. However, taking regular, short movement breaks like walking and stretching may help alleviate your pain, improve joint stiffness, and even reduce your fatigue.”
3 Symptoms Stress
Followed Up
Description: Mrs. Tillman has still been having constant fatigue and joint pain in her hands and wrists; she is frustrated about her symptoms and anxious about her health.
What are you sad about?
Question
07:09 PM EDT
Well, I’m still feeling so fatigued and I’m just sad because I feel like it’s not getting any better . . . I just don’t want to feel like this anymore.
Am sorry about that
Empathize
07:10 PM EDT
Thanks.
Model Statement: “I’m sorry to hear that you have been distressed about your symptoms and are still experiencing so much fatigue and joint pain. I know it is frustrating and stressful not having a diagnosis yet, but we’ll work on improving your symptoms and getting you some answers.” Musculoskeletal Shoshanna Tillman Follow Up Sick Visit Shadow Health Treatment Plan
4 Work Stress
Followed Up
Description: Mrs. Tillman’s art gallery requires a lot of her time and energy to sustain, but with her symptoms she is worried about her business and her family’s financial security.
Do you make enough money at your job?
Question
01:02 PM EDT
Now, the gallery is turning a profit and we’re making sufficient income. It’s still a new business, so it’s taken a while to get it here, but that could change. Running a small business is hard and uncertain, especially in the art world.
Any stress?
Question
01:04 PM EDT
Yeah. I’m really stressed with everything on my plate right now.
I’m sorry about that Musculoskeletal Shoshanna Tillman Follow Up Sick Visit Shadow Health Treatment Plan
Empathize
01:05 PM EDT
Thank you, that’s nice.
Model Statement: “It must be challenging and time consuming to run a small business. I know that your symptoms are causing you distress and have made an impact on your ability to work. We will work on improving your symptoms so you can resume your responsibilities.” Musculoskeletal Shoshanna Tillman Follow Up Sick Visit Shadow Health Treatment Plan
