Telehealth Follow Up Sick Visit: Liam Fitzgerald Shadow Health Treatment Plan
Telehealth Follow Up Sick Visit: Liam Fitzgerald 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.
| Learner Selection | Model Documentation |
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Diagnosis: xx Evidences: Weight gain Elevated systolic pressure Fatigue with activity Pitting edema Learner Rationale: The above evidence confirm the diagnosis of xx Score: 5 out of6 |
Diagnosis: xx Primary: xx Evidences: Fatigue with activity Pitting edema Report of increased sodium consumption Weight gain Model Rationale: Mr. Fitzgerald’s primary diagnosis is xx, with a secondary diagnosis of acute on xx. The xxxx has exacerbated his chronic condition. Mr. Fitzgerald’s signs and symptoms of weight pain, pitting edema, fatigue with activity, and self-reported sodium increase have contributed to his xxx. His elevated diastolic and systolic pressures confirm a worsening condition. For patients with co-morbidities and chronic conditions, examining signs and symptoms at the root of the cause will help you determine why the chronic condition is worsening. Mr. Fitzgerald’s xx is exacerbated and secondary to the xx he is experiencing. |
Additional Diagnosis
| Learner Selection | Model Documentation |
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Diagnosis: xx Evidences: Elevated diastolic pressure Elevated systolic pressure Fatigue with activity Pitting edema Report of increased sodium consumption Weight gain Learner Rationale: Patient reports the above symptoms, Score: 7 out of 7 |
Diagnosis: xx Evidences: Elevated diastolic pressure Elevated systolic pressure Fatigue with activity Pitting edema Report of increased sodium consumption Weight gain Model Rationale: Mr. Fitzgerald’s primary diagnosis is xx with diastolic dysfunction. The fluid volume overload has exacerbated his chronic condition. Mr. Fitzgerald’s signs and symptoms of weight pain, pitting edema, fatigue with activity, and self-reported sodium increase have contributed to his Telehealth Follow Up Sick Visit: Liam Fitzgerald Shadow Health Treatment Plan. His elevated diastolic and systolic pressures confirm a worsening condition. For patients with co-morbidities and chronic conditions, examining signs and symptoms at the root of the cause will help you determine why the chronic condition is worsening. Mr. Fitzgerald’s CHF is exacerbated and secondary to the fluid volume overload he is experiencing. |
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 |
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Pharmacological Intervention
Selected: Yes Learner Rationale: Patient needs heart medications Score: 0 out of 1 |
Recommended: No
Mr. Fitzgerald does not require any new pharmacological interventions at this time because the necessary medications have already been prescribed. Mr. Fitzgerald now needs to recognize when it is appropriate to use his PRN medications furosemide 20 mg and potassium chloride tablet 10 mEq. |
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Non-Pharmacological Intervention
Selected: Yes Learner Rationale: Diet plan Score: 1 out of 1 |
Recommended: Yes
You should advise Mr. Fitzgerald on strategies to determine and remember when to use his PRN medications furosemide 20 mg and potassium chloride tablet 10 mEq. |
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Educate Patient
Selected: Yes Learner Rationale: Patient education on healthy lifestyle Score: 1 out of 1 |
Recommended: Yes
You will need to educate Mr. Fitzgerald about his activity level, diet, medications, and signs and symptoms in the next treatment plan activity. |
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Preventive Screening and Intervention
Selected: No Learner Rationale: No preventive interventions on my side Score: 1 out of 1 |
Recommended: No
At this time, it is not appropriate to conduct any preventative screenings or interventions for the patient as he is being treated for a sick visit. Recommending preventative screens and interventions at this time are beyond the scope of this visit. Preventative screenings and interventions can be recommended during an annual wellness visit or another visit. |
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Diagnostic Testing: Labs and Imaging
Selected: No Learner Rationale: No diagnostics needed Score: 1 out of 1 |
Recommended: No
As the patient’s diagnosis is evident, no further diagnostic testing is needed. |
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Referral of Care
Selected: Yes Learner Rationale: Refer to cardiologist Score: 0 out of 1 |
Recommended: No
There’s no evidence that the patient requires any referral to another healthcare provider at this time. Telehealth Follow Up Sick Visit: Liam Fitzgerald Shadow Health Treatment Plan |
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Continued Care and Follow-up
Selected: Yes Learner Rationale: Treatment evaluation in 2 weeks Score: 1 out of 1 |
Recommended: Yes
You should inform Mr. Fitzgerald to follow up on his chronic condition with his cardiologist and to schedule an additional follow-up telehealth appointment in two to three weeks for continued monitoring of his congestive heart failure. It is also good practice to remind patients to schedule their annual physicals and wellness visits. |
Topic: Activity
| Learner Selection | Model Documentation |
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It is important that you maintain your activity level; however, if you notice that you are having difficulty completing your daily activities or get fatigued, have chest pain, or shortness of breath during exercise, discontinue the exercise until you follow-up with your cardiologist.
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It is important that you maintain your activity level; however, if you notice that you are having difficulty completing your daily activities or get fatigued, have chest pain, or shortness of breath during exercise, discontinue the exercise until you follow-up with your cardiologist. |
| Score: 1 out of 1 |
Topic: Diet
| Learner Selection | Model Documentation |
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Do not consume more than 500 ml of alcohol within a 24 hour period.
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You should adhere to your low-sodium diet as much as possible. Pay attention to labels and avoid foods high in sodium so you are aware of your level of sodium consumption. |
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You should avoid drinking alcohol since it can impact fluid volume overload.
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You should avoid drinking alcohol since it can impact fluid volume overload. Telehealth Follow Up Sick Visit: Liam Fitzgerald Shadow Health Treatment Plan |
