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Telehealth Follow Up Sick Visit: Liam Fitzgerald Shadow Health Treatment Plan

Telehealth Follow Up Sick Visit: Liam Fitzgerald Shadow Health Treatment Plan

Treatment Plan: 34 of 36 (94.44%)

Problem Selection
12 out of 13

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: 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

 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: 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

Pharmacological Intervention

Selected: Yes

Learner Rationale:

Patient needs heart medications

Score: 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.

Non-Pharmacological Intervention

Selected: Yes

Learner Rationale:

Diet plan

Score: 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.

Educate Patient

Selected: Yes

Learner Rationale:

Patient education on healthy lifestyle

Score: 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.

Preventive Screening and Intervention

Selected: No

Learner Rationale:

No preventive interventions on my side

Score: 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.

Diagnostic Testing: Labs and Imaging

Selected: No

Learner Rationale:

No diagnostics needed

Score: 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:

Refer to cardiologist

Score: 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

Continued Care and Follow-up

Selected: Yes

Learner Rationale:

Treatment evaluation in 2 weeks

Score: 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.

Education
15 out of 16

Topic: Activity

Learner Selection
Model Documentation

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.

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

Do not consume more than 500 ml of alcohol within a 24 hour period.

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.

You should avoid drinking alcohol since it can impact fluid volume overload.

You should avoid drinking alcohol since it can impact fluid volume overload. Telehealth Follow Up Sick Visit: Liam Fitzgerald Shadow Health Treatment Plan

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