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.

Shoshanna Tillman Musculoskeletal Shadow Health

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.

Additional Diagnosis

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, general 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 professionals 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

1 Caffeine

Followed Up

Description: Mrs. Tillman has been drinking large quantities of coffee to make up for her low energy.

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Question 12:58 PM EDT Shoshanna Tillman

I do. I’ll have somewhere between 2 to 3 cups of coffee in the morning, then another one or two in the afternoon.

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OK, but too much caffeine is not good for your health

Educate 12:58 PM EDT Shoshanna Tillman

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.

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Question 12:58 PM EDT Shoshanna Tillman

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.

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I understand your concern but you should always exercise

Educate 01:00 PM EDT Shoshanna Tillman

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.

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Question 07:09 PM EDT Shoshanna Tillman

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.

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Am sorry about that

Empathize 07:10 PM EDT Shoshanna Tillman

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.”

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.

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Question 01:02 PM EDT Shoshanna Tillman

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.

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Any stress?

Question 01:04 PM EDT Shoshanna Tillman

Yeah. I’m really stressed with everything on my plate right now.

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I’m sorry about that

Empathize 01:05 PM EDT Shoshanna Tillman

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.”