Category: Nursing

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Adolescent Sports Evaluation shadow health Objective data

Objective Data Collection: 23 of 23 (100%)

 Correct

 Partially correct

 Incorrect

 Missed

 Growth Chart: Height & Weight

1 of 1 point

Weight Percentile 
(1/4 point)

 Below 5th percentile

 Between 5th and 95th percentile

 Above 95th percentile

Adolescent Sports Evaluation shadow health Objective data

Weight Growth Curve 
(1/4 point)

 Growth curve maintained

 Growth curve decline

Height Percentile 
(1/4 point)

 Below 5th percentile

 Between 5th and 95th percentile

 Above 95th percentile

Height Growth Curve 
(1/4 point)

 Growth curve maintained

 Growth curve declined

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 Inspected Skin

1 of 1 point

Lesions 
(1/5 point)

 No visible lesions

 Lacerations/wounds

 Erythema

 Ecchymosis

 Birthmark

 Discolorations

Color 
(1/5 point)

 Consistent with ethnic background

 Jaundice

 Cyanosis

 Pallor

Texture 
(1/5 point)

 Smooth

 Rough

Temperature 
(1/5 point)

 Warm

 Cool

Skin Hydration 
(1/5 point)

 Elastic

 Elastic Tenting

 Sluggish Turgor

 Inspected General Appearance

1 of 1 point

Posture 
(1/2 point)

 Upright posture without tension or rigidity

 Bent or hunched posture, tension or rigidity

Adolescent Sports Evaluation shadow health Objective data

Clothing 
(1/2 point)

 Clean clothing, appropriate for age, fit, season and occasion

 Dirty, disheveled, or inappropriate to age, fit, season or occasion

 Assessed Cervical Spine RoM

1 of 1 point

Flexion 
(1/4 point)

 Expected range of motion (approx. 45)

 Reduced range of motion

Extension 
(1/4 point)

 Expected range of motion (approx. 45)

 Reduced range of motion

Lateral Bending 
(1/4 point)

 Expected range of motion (approx. 40) on both sides

 Reduced range of motion on right

 Reduced range of motion on left

Rotation 
(1/4 point)

 Expected range of motion (approx. 70) on both sides

 Reduced range of motion on right

 Reduced range of motion on left

 Assessed Spine Range of Motion

1 of 1 point

Rotation 
(1/1 point)

 Expected range of motion (approx. 75-90 degrees)

 Reduced flexion

 Assessed Wrist RoM

1 of 1 point

Left Extension 
(1/4 point)

 Expected range of motion (approx. 90 degrees)

 Reduced flexion

Right Extension 
(1/4 point)

 Expected range of motion (approx. 90 degrees)

 Reduced extension

Adolescent Sports Evaluation shadow health Objective data

Left Flexion 
(1/4 point)

 Expected range of motion (approx. 90 degrees)

 Reduced flexion

Right Flexion 
(1/4 point)

 Expected range of motion (approx. 90 degrees)

 Reduced flexion

 Assessed Elbow RoM

1 of 1 point

Left: Flexion And Extension 
(1/4 point)

 Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)

 Reduced Extension

 Reduced Flexion

Right: Flexion And Extension 
(1/4 point)

 Expected range of motion (approx. flexion of 160 degrees and 180 degrees of full extension)

 Reduced Extension

 Reduced Flexion

Left: Supination And Pronation 
(1/4 point)

 Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)

 Reduced Pronation

 Reduced Supination

Right: Supination And Pronation 
(1/4 point)

 Expected range of motion (approx. pronation of 90 degrees and 90 degrees of supination)

 Reduced Pronation

 Reduced Supination

 Assessed Shoulder RoM

1 of 1 point

Adduction 
(1/3 point)

 Expected range of motion (approx. 50 degrees)

 Reduced range of motion

Abduction 
(1/3 point)

 Expected range of motion (approx. 50 degrees)

 Reduced range of motion

Strength 
(1/3 point)

 0 – No muscle contraction

 1 – Barely detectable contraction

 2 – Active movement with gravity eliminated

 3 – Active movement against gravity

 4 – Active movement against gravity and resistance

 5 – Active movement against full resistance without fatigue (normal)

 Assessed Trapezius Strength

1 of 1 point

Strength 
(1/1 point)

 0 – No muscle contraction

 1 – Barely detectable contraction

 2 – Active movement with gravity eliminated

 3 – Active movement against gravity

 4 – Active movement against gravity and resistance

 5 – Active movement against full resistance without fatigue (normal)

Adolescent Sports Evaluation shadow health Objective data

 Assessed Deltoid Strength And Shoulder Rotation

1 of 1 point

Strength & Rotation 
(1/3 point)

 Symmetric

 Asymmetric

Forward Flexion 
(1/3 point)

 Expected range of motion (approx. 180 degrees)

 Reduced range of motion

Extension 
(1/3 point)

 Expected range of motion (approx. 50 degrees)

 Reduced range of motion

 Assessed Hand/Finger RoM And Strength

1 of 1 point

Left 
(1/2 point)

 0 – No muscle contraction

 1 – Barely detectable contraction

 2 – Active movement with gravity eliminated

 3 – Active movement against gravity

 4 – Active movement against gravity and resistance

 5 – Active movement against full resistance without fatigue (normal)

Right 
(1/2 point)

 0 – No muscle contraction

 1 – Barely detectable contraction

 2 – Active movement with gravity eliminated

 3 – Active movement against gravity

 4 – Active movement against gravity and resistance

 5 – Active movement against full resistance without fatigue (normal)

 Assessed Symmetry of Extremities

1 of 1 point

Extremities 
(1/1 point)

 Symmetrical

 Asymmetrical

 Assessed Leg Symmetry, Knee or Ankle Effusion

1 of 1 point

Effusion 
(1/3 point)

 Present

 Not present

Leg Symmetry 
(1/3 point)

 Symmetric

 Asymmetric

Knee Symmetry 
(1/3 point)

 Symmetric

 Asymmetric

 Assessed Calf Symmetry, Leg Strength

1 of 1 point

Calf Muscles 
(1/2 point)

 Symmetric

 Asymmetric

Leg Strength 
(1/2 point)

 0 – No muscle contraction

 1 – Barely detectable contraction

 2 – Active movement with gravity eliminated

 3 – Active movement against gravity

 4 – Active movement against gravity and resistance

 5 – Active movement against full resistance without fatigue (normal)

 Tested Hip, Knee and Ankle Range of Motion

1 of 1 point

Hip Range Of Motion 
(1/3 point)

 Symmetric, full range of motion without limitations

 Asymmetric range of motion with limitations

Knee Range Of Motion 
(1/3 point)

 Symmetric, full range of motion without limitations

 Asymmetric range of motion with limitations

Ankle Range Of Motion 
(1/3 point)

 Symmetric, full range of motion without limitations

 Asymmetric range of motion with limitations

 Tested 6 Cardinal Fields of Vision

1 of 1 point

Cardinal Fields 
(1/2 point)

 No abnormal findings

 Nystagmus

 Fixed Pupil

Convergence 
(1/2 point)

 No abnormal findings

 Unequal bilaterally

 Fixed Pupil

 Tested Peripheral Vision

1 of 1 point

Observations 
(1/1 point)

 No abnormal findings

 Reduced right visual field

 Reduced left visual field

 Tested Visual Acuity

1 of 1 point

Right 
(1/2 point)

 20/100

 20/70

 20/50

 20/40

 20/30

 20/25

 20/20

 20/15

 20/13

 20/10

Left 
(1/2 point)

 20/100

 20/70

 20/50

 20/40

 20/30

 20/25

 20/20

 20/15

 20/13

 20/10

 Romberg Test

1 of 1 point

Romberg 
(1/1 point)

 Maintains upright posture

 Difficulty remaining upright

 Auscultated Breath Sounds

1 of 1 point

Breath Sounds 
(1/2 point)

 Clear in all areas

 Diminished in some areas

 Absent in some areas

Adventitious Sounds 
(1/2 point)

 No adventitious sounds

 Wheezing

 Fine crackles

 Stridor

 Rhonchi

 Rales

 Auscultated Abdominal Aorta

1 of 1 point

Sounds 
(1/1 point)

 No bruit

 Bruit

 Auscultated Heart Sounds

1 of 1 point

Heart Sounds 
(1/3 point)

 S1 and S2 audible

 S1, S2, and S3 audible

 S1, S2 and S4 audible

 S1, S2, S3 and S4 audible

Extra Heart Sounds 
(1/3 point)

 No extra sounds

 Gallops

 Murmur

 Friction rub

 Valve clicks

Rate And Rhythm 
(1/3 point)

 Regular rate and rhythm

 Irregular rate and rhythm

 Arrhythmia

 Screened Adam’s Forward Bend

1 of 1 point

Iliac Crests 
(1/6 point)

 Equal height

 Unequal height

Scapula Prominence And Shape 
(1/6 point)

 Equal height

 Unequal height

Spine Contour 
(1/6 point)

 Expected curvature

 Decreased lordosis

 Increased lordosis

 Decreased kyphosis

 Increased kyphosis

Spine Symmetry 
(1/6 point)

 Symmetrical

 Asymmetrical

Waistline 
(1/6 point)

 Equal height

 Unequal height

Flexion 
(1/6 point)

 Expected range of motion (approx. 75-90 degrees)

 Reduced flexion

Adolescent Sports Evaluation shadow health Objective data

Samantha Monroe shadow health Documentation

Documentation / Electronic Health Record

My Provider Notes

Student Documentation

Model Documentation

Subjective

Ms. Monroe is a 13 year old female presenting for a preparticipation evaluation so she can play soccer this year. Past Medical History: No current medical problems. Tonsillectomy as a child. Medications: No prescription medications. Takes multivitamin and apple cider vinegar. Nutrition: Eats a Mediterranean diet and avoids sweets, processed foods, and white carbs. Skips lunch 1-2 times a week. Physical Activity: Plays soccer on weekends. Family Medical History: No family history of genetic heart problems. Review of Systems HEENT: Denies eye, vision, and hearing problems. Cardiovascular: Denies chest pain during exercise, hear problems. Respiratory: Denies breathing problems during exercise. Musculoskeletal: Denies joint or muscle injuries. Genitourinary: Denies starting menses.

 

 

 

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Ms. Monroe is a 13 year old female who presents today for her sports preparticipation evaluation so she can play soccer this year. She had her annual well visit 6 months ago. Past Medical History: No current medical concerns. Had a tonsillectomy as a child. Denies any missing organs. Medications: Currently not taking any prescription medications, Daily Multivitamin and drinks Apple Cider Vinegar, 1 tablespoon a day with water. No known medication allergies Nutrition: Eats a Mediterranean diet and avoids sweets, “white carbs” and processed foods. Skips lunch 1-2 times a week for the last month. Physical Activity: Plays recreational soccer on the weekends, but really wants to play for her school team. Family Medical History: Denies history of any family members with genetic heart conditions, denies any family members with early cardiac death. Social History: Reports following a Mediterrranean diet, avoiding “white carbs”, and processed foods. Skips lunch 1-2 times a week. Feels like she needs to lose her baby fat so she can look like her friends. Feels like she does not fit in and wants to look athletic. Review of Systems HEENT: Denies eye problems, vision difficulties, and hearing problems. Cardiovascular: Denies any chest pain during exercise, denies history of cardiac issues, denies any prior cardiac tests. Respiratory: Denies shortness of breath during exercise. Musculoskeletal: Report sprained ankle at age 10. Denies any current muscle or joint injuries. Neurological: Denies syncope with exercise, positive for intermittent dizziness 1-2 times after skipping lunch. Denies head injury or concussions, denies numbness, tingling or weakness. Integumentary: Denies rashes. Genitourinary: Denies starting menses.

Objective

Vitals: H 62 in., W 49.9 kg, BP 112/70, T 36.6C, HR 78 RR 16 General: Pleasant 13-year old in no acute distress. HEENT: Symmetrical head. Eyes PERLA, EOM intact. Neck with full ROM Respiratory: Symmetrical chest rise and fall, lungs clear to auscultation. Samantha Monroe shadow health Documentation CV: S1, S2 present, RRR, no murmurs or gallops. Abd: No bruit in abdomen aorta. MSK: Symmetrical bilateral extremities. Full ROM. Skin: Warm, no rash or lesions. Neuro: Alert and oriented x3, intact balance, steady gait. Samantha Monroe shadow health Documentation

Vital signs: Length=62 in., Weight=49.9 kg, BMI= 20, Blood pressure=112/70, Temp=36.6C, Heart rate= 78/min, Resp=16 breaths/min General: Well-appearing 13-year-old in no acute distress. Upright posture without tension or rigidity, clothing clean and appropriate for season HEENT Head: Symmetrical Eyes: PERRLA, EOM intact, peripheral vision equal to examiner, vision 20/20 bilaterally Neck: Neck with full ROM Resp: Symmetrical chest rise and fall, smooth even respirations, bilateral lungs clear to auscultation CV: Regular rate and rhythm, S1S2 present, no murmurs, pulse present, equal bilaterally Abd: Abdomen aorta with no bruit noted MSK: Bilateral extremities symmetrical, FROM equally strength 5+ all extremities, Adam’s forward bend-equal iliac crest height, expected curvature of spine, scapula equal height, cervical spine full range of motion, lumbar spine-full range of motion, trapezius strength +5 bilaterally Neuro: Alert and oriented x3, balance intact, sensation intact Skin: Warm, smooth, congruent with genetic background. Elastic turgor. No lesions noted Hearing/Vision: Vision 20/20 uncorrected. Hearing intact

Assessment

Pre-participation sports physical Inappropriate diet and eating habits

Pre-Participation Sports Physical Inappropriate diet and eating habits

Plan

Pre-participation sports physical 1. Clear to participate in sports Inappropriate diet and eating habits Educate on healthy nutrition Discuss strategies for reducing shame around eating, weight. Educate on detecting problematic eating behaviors. RTC in 4 weeks for reevaluation.

Preparticipation physical 1. Clear to participate in sports Inappropriate diet and eating habits 1. Will provide education on healthy nutrition and the effects of nutrition on her body. 2. Discuss the potential life threatening problems caused by improper nutrition. 3. Healthy diet includes 3 meals a day and healthy snack options especially when exercising. 4. Discuss strategies for reducing shame around eating, weight and self-perception. Coping mechanisms around self-esteem and body image to include journaling, support group, relaxation, stress management, positive self talk and affirmations. 5. Limit media intake and refrain from watching shows on weight loss or dieting. 6. Educate on identifying problematic eating behaviors. Anticipatory Guidance Safety: Review sports safety measures including female athlete triad, injury prevention, sunscreen and sun protection, diet and nutritional supplements Follow-up Return to the clinic in 4 weeks to reevaluate nutrition and eating habits Samantha Monroe shadow health Documentation.

Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan

Treatment Plan: 21 of 21 (100.00%)

Problem Selection

8 out of 8

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 Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan. If there are multiple correct diagnoses, you will also receive a point for correctly selecting which diagnosis is the primary diagnosis.

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Learner Selection

Model Documentation

 Diagnosis: 
Pre-Participation Sports Physical

 Identified as primary

Evidences:

 
Samantha reports the reason for her visit is a sports physical

Learner Rationale:

The patient indicates that she came for a sports physical.

Score: 
3 
out of
 3

 Diagnosis: 
Pre-Participation Sports Physical

Primary: 
Yes

Evidences:

Samantha reports the reason for her visit is a sports physical

Model Rationale:

The primary diagnosis is the reason for the patient’s visit. Because Samantha has indicated she is in the office for her sports physical, the correct primary diagnosis is Pre-Participation Sports Physical. As a primary care provider, it is critical to properly code the reason for Samantha’s visit so it can be covered by insurance Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan.

Additional Diagnosis

Learner Selection

Model Documentation

 Diagnosis: 
Inappropriate Diet and Eating Habits

Evidences:

 
Samantha reports a desire to lose baby fat

 
Samantha reports dizziness

 
Samantha reports wanting to look more athletic

 
Samantha reports skipping lunch once or twice each week

Score: 
5 
out of
 5

 Diagnosis: 
Inappropriate Diet and Eating Habits

Evidences:

Samantha reports a desire to lose baby fat

Samantha reports dizziness

Samantha reports wanting to look more athletic

Samantha reports skipping lunch once or twice each week

Model Rationale:

Samantha’s desire to lose baby fat and appear more athletic, as well as her diet modifications, are clear indications that Samantha’s diagnosis pertains to Inappropriate Diet and Eating Habits. This subjective data, along with Samantha’s normal weight range and healthy BMI collected during physical examination, indicate that Samantha’s problematic behavior is not severe enough to meet the criteria of other eating-related diagnosis or disorders. Therefore, Inappropriate Diet and Eating Habits is the correct additional diagnosis at this time. American Psychiatric Association. (2017). Feeding and Eating Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.dsm10

Plan of Care

7 out of 7

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:
 No

Learner Rationale:

No disease or problem was indicated by the patient

Score: 
1 
out of
 1

Recommended:
 No

This selection is not appropriate. Samantha did not indicate any illness or problem during her sports physical that would require Pharmacological Intervention. Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan

Non-Pharmacological Intervention

Selected:
 Yes

Learner Rationale:

You should discuss with the patient about her food and dieting habits.

Score: 
1 
out of
 1

Recommended:
 Yes

Because you’ve uncovered some eating and body issues during Samantha’s visit, it is appropriate to perform Non-Pharmacological Interventions. You will talk to Samantha and Jackie about their attitudes and habits around food, dieting, and body image in order to interrupt Samantha’s disordered habits before they become more problematic. A more intuitive, holistic approach to healthy living will allow Samantha to shift her focus away from restrictive eating and weight loss towards a lifestyle that supports her well being.

Educate Patient

Selected:
 Yes

Learner Rationale:

Patient should be taught to take care of her own health.

Score: 
1 
out of
 1

Recommended:
 Yes

When a pediatric patient is old enough to take responsibility for their own care, you must educate them as well as their guardian. Clearly communicating to a patient and their guardian what care they need and why improves adherence and outcomes Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan.

Preventive Screening and Intervention

Selected:
 No

Learner Rationale:

Samantha already got preventive screening during her 134-year old well visit.

Score: 
1 
out of
 1

Recommended:
 No

This selection is not appropriate. Samantha already had her 13-year-old well visit where she was vaccinated and screened for preventative care.

Diagnostic Testing: Labs and Imaging

Selected:
 No

Learner Rationale:

No conditions were indicated that would require testing.

Score: 
1 
out of
 1

Recommended:
 No

This selection is not appropriate. Samantha did not indicate any conditions or issues that would require labs or testing.

Referral of Care

Selected:
 No

Learner Rationale:

This selection is not appropriate.

Score: 
1 
out of
 1

Recommended:
 No

This selection is not appropriate. It’s important to follow-up with Samantha about your initial intervention strategies before referring the patient out for specialized care.

Continued Care and Follow-up

Selected:
 Yes

Learner Rationale:

A follow-up appointment is essential to see how the patient is complying with non-pharmacological interventions

Score: 
1 
out of
 1

Recommended:
 Yes

Given Samantha’s inappropriate eating habits and body image concerns, a follow-up appointment to see how well she is adhering to the non-pharmacological interventions is an appropriate selection.

Non-Pharmacological Intervention

6 out of 6

Learner Selection

Model Documentation

Discuss life-threatening health problems caused by eating disorders, such as heart failure, bone loss, hair and tooth loss, and loss of menses.

Selected:
 Yes

Learner Rationale:

 

Score: 
1 
out of
 1

Recommended:
 Yes

Given Samantha’s lack of knowledge around the consequences of eating disorders, it is critical she understand the long-term consequences of poor nutrition. Samantha’s diagnosis of Inappropriate Diet and Eating Habits requires that Samantha understand the potential risks she is taking with her behavior. Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan Therefore, Discuss Life-threatening Health Problems is an appropriate selection at this time.

 

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Discuss limiting Samantha’s media intake, including unfollowing fitness accounts on social media and refraining from watching shows about weight loss or dieting.

Selected:
 Yes

Learner Rationale:

 

Score: 
1 
out of
 1

Recommended:
 Yes

Given that Samantha mentioned social media and peer pressure as influencing her body image and self-esteem, it is critical she limits her exposure to media that promotes dieting, weight loss, fitness, and idealized or unrealistic bodies. Samantha’s diagnosis of Inappropriate Diet and Eating Habits requires a holistic approach that considers the cultural factors that may influence her. Therefore, Limiting Media Intake is the appropriate selection at this time.

Discuss with Samantha various ways to track her calorie intake, including apps and food diaries, to ensure she meets her recommended caloric intake.

Selected:
 No

Learner Rationale:

 

Score: 
1 
out of
 1

Recommended:
 No

Given best practices and the details of Samantha’s case, this is an inappropriate intervention. Taking into account all of Samantha’s signs and symptoms, it is not appropriate to encourage Samantha to fixate further on calories or food intake. Eating Disorder Foundation. (n.d.). About eating disorders. https://eatingdisorderfoundation.org/learn-more/about-eating-disorders

Educate Samantha on identifying problematic eating behaviors, including skipping meals on purpose, misusing laxatives, counting calories, or purging via exercise or vomiting.

Selected:
 No

Learner Rationale:

 

Score: 
1 
out of
 1

Recommended:
 No

Given best practices and the details of Samantha’s case, this is an inappropriate intervention; however, Samantha could be educated on problematic eating behaviors, including in-depth examples like misusing laxatives or purging via exercise or vomiting may unintentionally give the patient more strategies to continue covert disordered eating. Eating Disorder Foundation. (n.d.). About eating disorders. https://eatingdisorderfoundation.org/learn-more/about-eating-disorders Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan

Increase knowledge of coping mechanisms for low self-esteem and poor body image, including journaling, support groups, relaxation and stress management, positive self-talk, and affirmations.

Selected:
 Yes

Learner Rationale:

 

Score: 
1 
out of
 1

Recommended:
 Yes

Given Samantha’s poor body image, desire to lose weight, and her tendency to compare herself to her peers, it is critical she develop positive coping mechanisms to build a more neutral, if not positive, approach to her body. Coping mechanisms may include journaling, support group, relaxation and stress management, positive self-talk, and affirmations. Samantha’s diagnosis of Inappropriate Diet and Eating Habits requires a patient-centered empathetic approach. Therefore, Increase Knowledge of Coping Mechanisms is the appropriate selection at this time.

Inform Samantha that if she sets her mind to it, she can overcome her body issues and low-self esteem through proper diet and exercise.

Selected:
 No

Learner Rationale:

 

Score: 
1 
out of
 1

Recommended:
 No

Given best practices and the details of Samantha’s case, this is an inappropriate intervention. Disordered eating arises from complex, overlapping factors such as culture, fatphobia, peer pressure, and anxiety. Informing Samantha that she can simply choose to overcome her low self-esteem is not a patient-centered intervention. Eating Disorder Foundation. (n.d.). About eating disorders. https://eatingdisorderfoundation.org/learn-more/about-eating-disorders

Education

In your own words, discuss life-threatening health problems related to disordered eating with Samantha and Ms. Monroe.

Learner Response

Model Response

Forcing yourself to diet or skip meals can make you very sick because strong bones teeth, and hair require adequate nutrition.

Eating as much as you should is a very important part of staying healthy. Forcing yourself to diet or skip meals can make you very sick. Strong bones, hair, and teeth all require sufficient nutrition and calories. Eating well is important for development. Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan You mentioned feeling self-conscious about not having your period yet, but you’re developing at a normal rate. Eating regularly will help you stay on track to develop properly, which includes getting your period. Also, you’re a soccer player — that requires a lot of energy and stamina. Eating plenty of food allows you to perform on the field and helps protect you from injury and overexertion. As an athlete, a student, and a young woman, having three meals of balanced food a day will help you achieve your goals.

Oh, um yeah. That makes sense. I don’t want any of that to happen.

Thank you. This is pretty concerning so we’ll take this very seriously.

In your own words, discuss limiting media intake with Samantha and Jackie.

Learner Response

Model Response

You should limit media exposure and remember that your body deserves to be fed, cared or, regardless of the size.

Samantha, you mentioned social media and your friends’ follower count as influencing your body-image. We’re going to talk about social media and strategies you can use to protect your mental health and body-image. It’s critical you limit your exposure to media sources that promote diet culture, fad diets, weight loss, fitness goals, and idealized, unrealistic bodies Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan. Instead of focusing on how you look in comparison to others, try to reframe those thoughts and remind yourself that your body isn’t a problem to be solved or punished. When you see images, articles, or TV shows that make you feel bad, turn them off and remember your body deserves to be fed, cared for, and appreciated, regardless of its size.

Yeah, I mean I don’t want an eating disorder or anything like that. I just thought thinking like that was pretty normal, but I guess not.

We’re just both going to have to rethink how we see our bodies and talk about nutrition. I don’t want to see my daughter struggle with her self-esteem.

In your own words, discuss increasing knowledge of coping mechanisms with Samantha and Jackie.

Learner Response

Model Response

You can try journalling, relaxation and stress management techniques, and affirmations

Now we’re going to talk about some specific coping strategies you can use to interrupt negative thoughts about yourself and work towards a more neutral, if not positive, approach to your body. You can try journaling, relaxation and stress management techniques, replacing negative self-talk with positive things you like and appreciate about yourself, and affirmations. A good affirmation for you might be, “All bodies deserve to be fed and watered,” or “All bodies deserve care and praise.” You can also consider going to a support group for teens looking to build-up their self-esteem. Body image and disordered eating can significantly impact a person’s anxiety levels and sense of control over their lives. Try using these coping strategies the next time you have anxious, controlling, or restrictive thoughts about your body or food.

Yeah, that make sense. It’s not like I want to feel this way, you know?

I’m just glad we figured out that this was an issue. I had no idea. Samantha Monroe Adolescent Sports Evaluation shadow health Treatment Plan

Samantha Monroe Adolescent Sports Evaluation shadow health

Transcript

Started:
 Mar 05, 2022 | 
Total Time:
 306 min

All Lines
(91)
Interview Questions (54)
Statements (9)
Exam Actions (28)

Hello. Am xxxx, I will interview you and later conduct a physical exam.

Greet

03/05/22 5:41 AM EST

Hello.

What is your relationship with the patient?

Question

03/05/22 5:42 AM EST

Oh, this is my mom.

Hey, I’m Jackie Monroe. This is my daughter, Samantha.

Why are you here today?

Question

03/05/22 5:42 AM EST

I’m here for a sports physical. I’m gonna play on my school soccer team. We’re called the Nightingales, which is pretty cool. Samantha Monroe Adolescent Sports Evaluation shadow health

Any medical issue?

Question

03/05/22 5:43 AM EST

Uh, nope. No health issues.

Any history of surgery?

Question

03/05/22 5:43 AM EST

I had my tonsils removed when I was like 9, but that’s it.

Yeah, that was Samantha’s only surgery.

Any missing organ? (No matching questions found.)

Question

03/05/22 5:45 AM EST

Does your daughter have any missing organ? (No matching questions found.)

Question

03/05/22 5:46 AM EST

Have you had any of your organs removed?

Question

03/05/22 5:46 AM EST

Uh . . . no. All my organs are 100% present.

Any allergies?

Question

03/05/22 5:49 AM EST

No, I’ve never had any allergies before.

Are your vaccinations current?

Question

03/05/22 5:50 AM EST

Yeah, I’ve had all my vaccines.

I always made sure she was up to date on her vaccinations.

Are you using any medications?

ORDER SHADOWHEALTH, IHUMAN, EXAM OR WRITTEN ASSIGNMENT HERE

Question

03/05/22 5:50 AM EST

No, I don’t take anything.

Are you using any vitamins or supplements?

Question

03/05/22 5:51 AM EST

I take a multivitamin. Plus, I drink apple cider vinegar, which is kinda like a supplement.

Do you pass out during exercise? (Clarified to Have you passed out during exercise?.)

Question

03/05/22 5:52 AM EST

No way. I’ve never passed out while I was exercising. (Clarified to if I have passed out during exercise.)

Any dizziness?

Question

03/05/22 5:53 AM EST

Oh, no. I feel totally fine right now.

Have you ever been dizzy? (Clarified to Have you felt dizzy in the past?.)

Question

03/05/22 5:53 AM EST

I’ve only been dizzy like once or twice. And that was because I skipped lunch and then had to go to gym class. (Clarified to if I have felt dizzy in the past.)

Am sorry about that

Educate

03/05/22 5:54 AM EST

Thanks for the heads-up.

Any heart problems after exercising? (Clarified to Have you had heart problems after exercise?.)

Question

03/05/22 5:56 AM EST

No heart problems after exercise. (Clarified to if I have had heart problems after exercise.) Samantha Monroe Adolescent Sports Evaluation shadow health

Have you had heart problems during exercise?

Question

03/05/22 5:57 AM EST

Nope. No problems during exercise.

Have you been diagnosed with a heart problem?

Question

03/05/22 5:58 AM EST

No, I’ve never been diagnosed with any heart problems that I know of.

No, no heart problems.

How is your breathing during and after exercise?

Question

03/05/22 5:59 AM EST

My breathing is fine during and after exercise.

Any history of seizures?

Question

03/05/22 6:00 AM EST

Pretty sure I’ve never ever had a seizure.

That is correct. No seizures or anything like that.

Any injuries?

Question

03/05/22 6:01 AM EST

Um, well I did sprain my ankle when I was like 10. That’s really it, though. I’m always good to play.

Any rashes?

Question

03/05/22 6:01 AM EST

No rashes. Ew.

Any history of head injuries?

Question

03/05/22 6:02 AM EST

Nope. My head’s fine.

Have you had a concussion?

Question

03/05/22 6:03 AM EST

I’ve never had a concussion, but I did see my friend wipeout at the skatepark once. It was crazy. He was skating, then boom. I was filming, so it was, you know, pretty scarring.

Any numbness or tingling?

Question

03/05/22 6:04 AM EST

No numbness or tingling. That sounds weird.

Any weakness in your limbs?

Question

03/05/22 6:09 AM EST

Nope, no weakness.

Do you exercise in the heat?

Question

03/05/22 6:14 AM EST

Sure. We do gym outside sometimes. When soccer season starts, practice and games are outside.

Any eye problems?

Question

03/05/22 6:16 AM EST

My eyes are fine.

Have you started your periods?

Question

03/05/22 6:17 AM EST

No, I haven’t started my period yet. It’s kind of weird because all my friends have? Whenever they talk about it, like the cramps or whatever, I just pretend like I’ve had mine, too. Just to fit in.

She asked how old I was when I got my first period. I told her I was about 12.

I understand your concerns, but it’s normal for a person of your age to not have started their periods yet.

Educate

03/05/22 6:20 AM EST

Cool. Good to know.

Tell me about your family medical history.

Question

03/05/22 6:21 AM EST

Wait, like the entire family medical history or do you mean something more specific?

Any genetic conditions in your family? (Clarified to Does anyone in your family have a genetic heart condition?.)

Question

03/05/22 6:22 AM EST

I don’t know. Mom? (Clarified to if anyone in my family has a genetic heart condition.)

No, no one in the family has any genetic heart conditions.

Any heart problems in your family?

Question

03/05/22 6:22 AM EST

I don’t think anyone has heart problems, but I’m not totally sure.

You know, I can’t think of anybody in the family who’s had heart problems.

Any history of unexpected deaths in your family? (No matching questions found.)

Question

03/05/22 6:23 AM EST

Any family history of unexpected deaths before the age of 35? (No matching questions found.)

Question

03/05/22 6:24 AM EST

Has any of your family members had a pacemaker before age 35? (Clarified to Has anyone in your family had a pacemaker before 35?.)

Question

03/05/22 6:25 AM EST

I’m not sure about the pacemaker thing. (Clarified to if anyone in my family had a pacemaker before thirty five.)

To my knowledge, there isn’t anyone in the family who’s ever had a pacemaker.

Do you feel your weight is okay? (Clarified to How do you feel about your weight?.)

Question

03/05/22 6:27 AM EST

Um, I mean, I wish I could lose this baby fat. All my friends wear one size smaller than me, so it’s super awkward when they’re swapping clothes . . . and talking about their periods . . . just hard not to compare. (Clarified to how I feel about my weight.)

I told her . . . middle school is tough, especially with all the social media they’re dealing with now. But luckily time goes by faster the older you get and one day you’re my age and it’s all in the rearview Samantha Monroe Adolescent Sports Evaluation shadow health.

I understand your concerns but you should not try to fit in or compare yourself to others.

Educate

03/05/22 6:29 AM EST

Gotcha.

Do you want to lose weight? (Clarified to Why do you think you need to lose weight?.)

Question

03/05/22 6:29 AM EST

Just . . . to look more athletic, you know. Like I fit in with everybody. (Clarified to why I think I need to lose weight.)

You should not try to fit in. Everyone is unique.

Educate

03/05/22 6:30 AM EST

Um, that makes sense.

Tell me about your diet.

Question

03/05/22 6:31 AM EST

I do the Mediterranean diet. It’s healthy. I try not to eat bad stuff. No candy, white carbs, processed food.

Do you skip any meals?

Question

03/05/22 6:32 AM EST

Yeah, I skip lunch once or twice each week.

It is not advisable to skip any meal at your age because you are still growing

Educate

03/05/22 6:33 AM EST

For sure. OK.

How long have you been skipping your lunch? (Clarified to How long have you been skipping lunch?.)

Question

03/05/22 6:34 AM EST

I started skipping lunch maybe a month ago? (Clarified to how long I have been skipping lunch.)

 Inspected weight and height growth chart

Exam Action

03/05/22 6:35 AM EST

 Inspected Skin

Exam Action

03/05/22 6:48 AM EST

 Assessed appearance

Exam Action

03/05/22 6:49 AM EST

 Assessed Cervical Spine Range of Motion

Exam Action

03/05/22 6:52 AM EST

 Assessed Spine Range of Motion: Full range of motion performed without discomfort

Exam Action

03/05/22 6:53 AM EST

 Assessed wrist range of motion

Exam Action

03/05/22 7:01 AM EST

 Assessed Elbow Range of Motion

Exam Action

03/05/22 7:03 AM EST

 Assessed range of motion of shoulders – adduction and abduction: Strength equal bilaterally against full resistance

Exam Action

03/05/22 7:06 AM EST

 Assessed Trapezius Strength: Strength equal bilaterally against full resistance

Exam Action

03/05/22 7:06 AM EST

 Assessed deltoid strength and shoulder rotation

Exam Action

03/05/22 7:07 AM EST

 Assessed Hand and Finger Range of Motion and Strength: Right and left hand strength equal bilaterally against resistance

Exam Action

03/05/22 7:08 AM EST

 Assessed Symmetry of Extremities

Exam Action

03/05/22 7:09 AM EST

 Assessed leg symmetry, knee and ankle effusion Samantha Monroe Adolescent Sports Evaluation shadow health

Exam Action

03/05/22 7:09 AM EST

 Assessed Calf Symmetry and Leg Strength

Exam Action

03/05/22 7:10 AM EST

 Tested Hip, Knee, and Ankle ROM

Exam Action

03/05/22 7:11 AM EST

 Tested Cardinal Fields of Vision

Exam Action

03/05/22 7:14 AM EST

 Tested peripheral vision

Exam Action

03/05/22 7:15 AM EST

 Tested visual acuity

Exam Action

03/05/22 7:15 AM EST

 Tested balance: Expected

Exam Action

03/05/22 7:16 AM EST

 Auscultated lungs

Exam Action

03/05/22 7:17 AM EST

 Auscultated abdomen

Exam Action

03/05/22 7:18 AM EST

 Auscultated heart

Exam Action

03/05/22 7:18 AM EST

 Screened Adam’s Forward Bend

Exam Action

03/05/22 7:20 AM EST

Mrs. Monroe please step out so I can have a private conversation with your daughter.

Educate

03/05/22 7:34 AM EST

Sure, no problem.

I will be asking you some personal questions and I need you to know that you are in a safe and a nonjudgmental environment.

Educate

03/05/22 7:36 AM EST

OK. That sounds alright.

Tell me about your school life, friends and hobbies.

Question

03/05/22 7:38 AM EST

Everything’s fine. I mean . . . My grades are average. I get a lot of Bs. I feel like my friends used to be really chill but I don’t know what happened this year. It’s like everybody got super skinny and so many more followers on their social accounts. Soccer is gonna be fun, for sure, but . . . everything was easier before I turned 13.

Am sorry about that. Everything will be fine.

Empathize

03/05/22 7:39 AM EST

Thanks. I’m glad you understand.

Tell me about your support system.

Question

03/05/22 7:41 AM EST

Yeah, me and my mom are pretty close, and I have some friends who get it. We talk and stuff.

Have you ever used tobacco?

Question

03/05/22 7:42 AM EST

Definitely not. I feel like I’ve heard smoking can help you lose weight, but I’m not ever gonna do it because it’s so bad for your lungs. That would ruin my soccer game.

Have you used any drugs?

Question

03/05/22 7:43 AM EST

No. I wouldn’t ever do drugs.

Have you used alcohol?

Question

03/05/22 7:44 AM EST

I don’t drink. No way.

Are you interested in relationships and dating?

Question

03/05/22 7:45 AM EST

I’m not really interested in that yet.

Are you sexually active?

Question

03/05/22 7:45 AM EST

No.

I would like to know more about your feeling of nervousness or anxiety.

Question

03/05/22 7:54 AM EST

I mean . . . school’s a lot. Projects and tests and stuff. And I want to do really well in soccer. But I guess it’s mostly the whole “keeping up with appearances” thing. It’s like a full-time job.

Am sorry about that.

Empathize

03/05/22 7:55 AM EST

Thanks.

I noticed that you are concerned about your body image, weight, and diet.

Question

03/05/22 7:57 AM EST

Well, I’ve definitely started paying more attention to health stuff, but I thought that was a good thing. I just want to post a selfie and not have a double-chin, you know?

Have you ever considered doing anything more extreme to manage your weight?

Question

03/05/22 7:58 AM EST

No, I wouldn’t do anything dangerous. I promise.

Do you have any questions for me?

Question

03/05/22 7:59 AM EST

No, I don’t think so.

 You will now discuss the appropriate non-pharmacological interventions with Samantha and her mother, Ms. Monroe. 
You will not be automatically scored on your choices or responses in this activity, but your instructor may choose to review your responses.

Exam Action

03/06/22 8:19 AM EST

I am ready to begin the conversation with Samantha.

Question

03/06/22 8:20 AM EST

 In your own words, discuss life-threatening health problems related to disordered eating with Samantha and Ms. Monroe.

Exam Action

03/06/22 8:20 AM EST

Forcing yourself to diet or skip meals can make you very sick because strong bones teeth, and hair require adequate nutrition.

Question

03/06/22 8:23 AM EST

Oh, um yeah. That makes sense. I don’t want any of that to happen.

Thank you. This is pretty concerning so we’ll take this very seriously.

 In your own words, discuss limiting media intake with Samantha and Jackie.

Exam Action

03/06/22 8:24 AM EST

You should limit media exposure and remember that your body deserves to be fed, cared or, regardless of the size.

Question

03/06/22 8:30 AM EST

Yeah, I mean I don’t want an eating disorder or anything like that. I just thought thinking like that was pretty normal, but I guess not.

We’re just both going to have to rethink how we see our bodies and talk about nutrition. I don’t want to see my daughter struggle with her self-esteem.

 In your own words, discuss increasing knowledge of coping mechanisms with Samantha and Jackie.

Exam Action

03/06/22 8:33 AM EST

You can try journalling, relaxation and stress management techniques, and affirmations

Question

03/06/22 8:58 AM EST

Yeah, that make sense. It’s not like I want to feel this way, you know?

I’m just glad we figured out that this was an issue. I had no idea.

 You have provided Samantha and her mother education on all appropriate non-pharmacological interventions.

 

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

Opportunities marked as 
Followed Up
 were followed up by students, and include the dialogue between student and patient

 1 Fitting in

Followed Up

 Description: 
Samantha feels like she doesn’t fit in with her peers.

Do you want to lose weight? (Clarified to: Why do you think you need to lose weight?)

Question

06:29 AM EST

Just . . . to look more athletic, you know. Like I fit in with everybody. (Clarified to: why I think I need to lose weight)

You should not try to fit in. Everyone is unique.

Educate

06:30 AM EST

Um, that makes sense.

 Model Statement: 
“At age 13, there are a lot of social pressures, coming from your friends at school, teammates at soccer, and influencers on social media. It’s important to be a part of a community that accepts and supports you. If you don’t feel accepted or supported, then you should feel comfortable discussing these issues with people you do trust, because that environment might not be healthy for you. It’s also possible that you’re being hard on yourself. I know it’s tempting to compare yourself to others, but don’t let that damage your self-worth.”

 2 Body Image

Followed Up

 Description: 
Samantha has insecurities about her body image.

Do you feel your weight is okay? (Clarified to: How do you feel about your weight?)

Question

06:27 AM EST

Um, I mean, I wish I could lose this baby fat. All my friends wear one size smaller than me, so it’s super awkward when they’re swapping clothes . . . and talking about their periods . . . just hard not to compare. (Clarified to: how I feel about my weight)

I understand your concerns but you should not try to fit in or compare yourself to others.

Educate

06:29 AM EST

Gotcha.

 Model Statement: 
“Samantha, you’ve mentioned wanting to lose baby fat and look athletic. I’m really sorry you’re having a hard time with the way people see you and the way you see yourself, but there’s nothing wrong with how you look, and you’re in good health. I know it’s easy for me to say this here in the clinic and hard for you when you’re getting compared to other people, but there’s nothing you need to change about yourself.”

 3 Menstruation

Followed Up

 Description: 
Samantha has concerns that she should have had her first period already.

Have you started your periods?

Question

06:17 AM EST

No, I haven’t started my period yet. It’s kind of weird because all my friends have? Whenever they talk about it, like the cramps or whatever, I just pretend like I’ve had mine, too. Just to fit in.

I understand your concerns, but it’s normal for a person of your age to not have started their periods yet.

Educate

06:20 AM EST

Cool. Good to know.

 Model Statement: 
“Knowing that your classmates are having their periods when you haven’t had one yet can be frustrating, but you don’t have anything to worry about. It’s typical for someone your age to not have started menstruating yet, and we can expect it to happen before you are 15. Everyone’s experience is a little bit different—sometimes I have patients who are concerned at how early they started. You’re prepared for your first period when it happens, and you’re comfortable talking about it here. That’s the maturity that matters, so do your best not to worry about where your peers are.”

 4 Skipping Meals

Followed Up

 Description: 
Samantha says that she skips lunch once or twice a week to reduce her caloric intake.

Do you skip any meals?

Question

06:32 AM EST

Yeah, I skip lunch once or twice each week.

It is not advisable to skip any meal at your age because you are still growing

Educate

06:33 AM EST

For sure. OK.

 Model Statement: 
“It’s very important to eat lunch, along with the rest of your regular meals. You’re still growing, and that takes a lot of food and energy. You’re also a soccer player, and athletes need plenty of calories and nutrients to play well and stay healthy. You definitely don’t need to feel bad about eating lunch. On top of that, skipping meals can feel pretty bad. When I miss lunch, I get a headache and feel cranky. Please go easy on yourself and your body and try not to skip lunch anymore.”

Treatment Plan
: 21 of 21 (100.00%)

Problem Selection

8 out of 8

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 Samantha Monroe Adolescent Sports Evaluation shadow health.

Learner Selection

Model Documentation

 Diagnosis: 
Pre-Participation Sports Physical

Identified as primary

Evidences:

Samantha reports the reason for her visit is a sports physical

Learner Rationale:

The patient indicates that she came for a sports physical.

Score: 
3 
out of
 3

 Diagnosis: 
Pre-Participation Sports Physical

Primary: 
Yes

Evidences:

Samantha reports the reason for her visit is a sports physical

Model Rationale:

The primary diagnosis is the reason for the patient’s visit. Because Samantha has indicated she is in the office for her sports physical, the correct primary diagnosis is Pre-Participation Sports Physical. As a primary care provider, it is critical to properly code the reason for Samantha’s visit so it can be covered by insurance.

Additional Diagnosis

Learner Selection

Model Documentation

 Diagnosis: 
Inappropriate Diet and Eating Habits

Evidences:

Samantha reports a desire to lose baby fat

Samantha reports dizziness

Samantha reports wanting to look more athletic

Samantha reports skipping lunch once or twice each week

Score: 
5 
out of
 5

 Diagnosis: 
Inappropriate Diet and Eating Habits

Evidences:

Samantha reports a desire to lose baby fat

Samantha reports dizziness

Samantha reports wanting to look more athletic

Samantha reports skipping lunch once or twice each week

Model Rationale:

Samantha’s desire to lose baby fat and appear more athletic, as well as her diet modifications, are clear indications that Samantha’s diagnosis pertains to Inappropriate Diet and Eating Habits. This subjective data, along with Samantha’s normal weight range and healthy BMI collected during physical examination, indicate that Samantha’s problematic behavior is not severe enough to meet the criteria of other eating-related diagnosis or disorders. Therefore, Inappropriate Diet and Eating Habits is the correct additional diagnosis at this time. American Psychiatric Association. (2017). Feeding and Eating Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.dsm10

Plan of Care

7 out of 7

Review your answers for the Plan of Care activity. You must select “Yes” or “No” for each of the seven care actions. Samantha Monroe Adolescent Sports Evaluation shadow health You will receive one point for determining the correct answer for each care action.

Learner Selection

Model Documentation

Documentation
/ Electronic Health Record

My Provider Notes

Student Documentation

Model Documentation

Subjective

Ms. Monroe is a 13 year old female presenting for a preparticipation evaluation so she can play soccer this year. Past Medical History: No current medical problems. Tonsillectomy as a child. Medications: No prescription medications.

Objective Data Collection
: 23 of 23 (100%)

 Correct

 Partially correct

 Incorrect

 Missed

 Growth Chart: Height & Weight

1 of 1 point

Weight Percentile 
(1/4 point)

 Below 5th percentile

 Between 5th and 95th percentile

 Above 95th percentile

Weight Growth Curve 
(1/4 point)

 Growth curve maintained

 Growth curve decline

Height Percentile 
(1/4 point)

 Below 5th percentile

 Between 5th and 95th percentile

 Above 95th percentile

Height Growth Curve 
(1/4 point)

 Growth curve maintained

 Growth curve declined

 Inspected Skin

1 of 1 point

Lesions 
(1/5 point)

 No visible lesions

Subjective Data Collection
: 26 of 27 (96.3%)

Hover To Reveal…

Hover over the 
Patient Data 
items below to reveal important information, including 
Pro Tips
 and 
Example Questions Samantha Monroe Adolescent Sports Evaluation shadow health
.

Found:

 Indicates an item that you found.

Available:

 Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Confirmed Guardian’s Relationship

Finding:

Asked about relationship with patient Samantha Monroe Adolescent Sports Evaluation shadow health

Zachary LaFontaine Infant Well Visit Shadow health Anticipatory Guidance

Anticipatory Guidance: 7.5 of 10.5 (71.43%)

 

Social Language and Self Help

1 out of 1

Learner Selection

Model Documentation

 
Laughter

 
Turns to parent for comfort

Laughter

Turns to parent for comfort

Verbal Language

0.5 out of 1

Learner Selection

Model Documentation

 
Extended cooing

 
Tries to mimic sounds that caretakers make

Extended cooing

Looks at people speaking

Fine Motor

1 out of 1

Learner Selection

Model Documentation

 
Can grasp objects

 
Can unfist hands

Can grasp objects

Can unfist hands

Gross Motor

0.5 out of 1

Learner Selection

Model Documentation

 
Can roll from stomach to back

 
Can sit without help for short periods

Can roll from stomach to back

Can lift self up with shoulders and wrists

Family Health

Zachary LaFontaine Infant Well Visit Shadow health Anticipatory Guidance

0.5 out of 1

Learner Selection

Model Documentation

 
Make sure not to alienate support network

 
Schedule a postpartum checkup

Schedule a postpartum checkup

Take time to care for your own health

Infant Care and Socialization

1.5 out of 2

Learner Selection

Model Documentation

 
Have regular, supervised tummy time

 
Interacting with the baby should include holding, speaking, and singing

 
Play games like peek-a-boo with the baby

 
Take notice of the baby’s signs of sleepiness and tiredness

Have regular, supervised tummy time

Interacting with the baby should include holding, speaking, and singing

Take notice of the baby’s signs of sleepiness and tiredness

Soothe the baby by stroking head, rocking, taking for a walk in stroller. Never use methods like shaking or hitting. Zachary LaFontaine Infant Well Visit Shadow health Anticipatory Guidance.

Feeding, Nutrition, and Elimination

1 out of 1.5

Learner Selection

Model Documentation

 
Expect 5 to 6 wet diapers and 3 to 4 stools a day

 
Position the baby so they can see you and socialize during feeding

 
The mother should remain on her prenatal multivitamin and eat a nutritious, high calorie diet

Expect 5 to 6 wet diapers and 3 to 4 stools a day

The mother should remain on her prenatal multivitamin and eat a nutritious, high calorie diet

Never feed the baby solid foods

Infant Safety and Supervision

1.5 out of 2 Zachary LaFontaine Infant Well Visit Shadow health Anticipatory Guidance

Learner Selection

Model Documentation

 
Always drive with the baby in a rear-facing car seat in the back seat

 
Always supervise the baby in high places and the bath

 
Feed the baby in a high chair

 
Keep a hand on the baby during activity

Always drive with the baby in a rear-facing car seat in the back seat

Always supervise the baby in high places and the bath

Keep a hand on the baby during activity

Make sure that the water heater at home is set to less than 120°F

Rationale

Learner Rationale

Model Rationale

Daanis, we know it is not easy to care for a baby, but we think you are doing a great job. With the help and support of your family continue caring for your son at tis important age.

After performing a complete assessment on Zachary and interviewing Daanis, I would evaluate the subjective and objective data collected. I would analyze Dannis’ areas of existing knowledge, areas for improvement, and opportunities for positive reinforcement. Addressing deficits in caretaker knowledge is crucial to promoting pediatric patient health and development. Zachary LaFontaine Infant Well Visit Shadow health Anticipatory Guidance. However, positive reinforcement encourages the guardian and bolsters their relationship with the patient. Zachary LaFontaine Infant Well Visit Shadow health Anticipatory Guidance

Zachary LaFontaine Shadow health Treatment Plan

Treatment Plan: 11 of 16 (68.75%)

Problem Selection

6 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. Zachary LaFontaine Shadow health Treatment Plan.

Learner Selection

Model Documentation

 Diagnosis: 
Encounter for routine child health examination with abnormal findings

 Identified as primary

Evidences:

 
Ms. LaFontaine reports that the reason for the visit is a well-child exam

Learner Rationale:

nothing

Score: 
2 
out of
 3

 Diagnosis: 
Encounter for routine child health examination with abnormal findings

Primary: 
Yes

Evidences:

Ms. LaFontaine reports that the reason for the visit is a well-child exam Zachary LaFontaine Shadow health Treatment Plan

Model Rationale:

The primary diagnosis is the reason for the patient’s visit. Because Ms. LaFontaine has indicated she has brought Zachary in for his well-child exam, the correct primary diagnosis is “Encounter for routine child health examination with abnormal findings.” As a primary care provider, it is critical to properly code the reason for Zachary’s visit so it can be covered by insurance. Zachary LaFontaine Shadow health Treatment Plan

Additional Diagnosis

Learner Selection

Model Documentation

 Diagnosis: 
Feeding Difficulty

Evidences:

 
Breasts are not always empty after feeding

 
Falling asleep while breastfeeding

 
Feeding sessions of insufficient length

 
Mother does not perceive enough time to feed

 
Mother does not consume enough calories

Learner Rationale:

I really found a normal developed infant

Score: 
4 
out of
 6

 Diagnosis: 
Feeding Difficulty

Evidences:

Breasts are not always empty after feeding

Zachary LaFontaine Shadow health Treatment Plan

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. Zachary LaFontaine Shadow health Treatment Plan 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. This leads to “Feeding difficulty” being the correct additional diagnosis. Kerzner B et al. (2015). Zachary LaFontaine Shadow health Treatment Plan A practical approach to classifying and managing feeding difficulties. Pediatrics, 135(2): 344.

Plan of Care

5 out of 7

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:
 No

Learner Rationale:

No for the infant. In the other hand, the mother will need suplements such as multivitamis

Score: 
0 
out of
 1

Recommended:
 Yes

Zachary may be deficient in Vitamin D, which is critical for infant bone and tooth development. Vitamin D deficiency is common in children who are breastfed, as breast milk contains no Vitamin D. You will recommend an OTC Vitamin D supplement to Daanis for Zachary to take. Zachary LaFontaine Shadow health Treatment Plan

Non-Pharmacological Intervention

Selected:
 Yes

Learner Rationale:

Infant nutrition, and breast feeding education.

Score: 
1 
out of
 1

Recommended:
 Yes

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:
 Yes

Learner Rationale:

as above

Score: 
1 
out of
 1

Recommended:
 Yes

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. Zachary LaFontaine Shadow health Treatment Plan

Preventive Screening and Intervention

Selected:
 No

Learner Rationale:

not need it

Score: 
0 
out of
 1

Recommended:
 Yes

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). 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:

not need it

Score: 
1 
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:

Breastfeeding education. Mother health, caloric intake, supplements or vitamis use.

Score: 
1 
out of
 1

Recommended:
 Yes

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:

in 2 months of before if needed.

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. Zachary LaFontaine Shadow health Treatment Plan . 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

Zachary LaFontaine Visit Shadow health Objective data

Objective Data Collection: 24.33 of 25 (97.32%)

 Correct

 Partially correct

 Incorrect

 Missed

 Growth Chart: Head Circumference

1 of 1 point

Head Circumference Percentile 
(1/2 point)

 Below 5th percentile

 Between 5th and 95th percentile

 Above 95th percentile

Head Circumference Growth Curve 
(1/2 point)

 Growth curve maintained

 Growth curve decline

Zachary LaFontaine Visit Shadow health Objective data

 Growth Chart: Weight and Length

0.83 of 1 point

Length Percentile 
(1/6 point)

 Below 5th percentile

 Between 5th and 95th percentile

 Above 95th percentile

Length Growth Curve 
(1/6 point)

 Growth curve maintained

 Growth curve decline

Weight Percentile 
(1/6 point)

 Below 5th percentile

 Between 5th and 95th percentile

 Above 95th percentile

Weight Growth Curve 
(No point)

 Growth curve maintained

 Growth curve decline

Weight For Length Percentile 
(1/6 point)

 Below 5th percentile

 Between 5th and 95th percentile

 Above 95th percentile

Weight For Length Growth Curve 
(1/6 point)

 Growth curve maintained

 Growth curve decline

Zachary LaFontaine Visit Shadow health Objective data

 Inspected Nose

1 of 1 point

Nares Inspection 
(1/3 point)

 Pale

 Pink

 Erythematous

Mucus 
(1/3 point)

 Thin white mucus present

 Thick yellow mucus present

Nares 
(1/3 point)

 Patent

 Obstructed, not patent single sided

 Inspected Ears

1 of 1 point

Inspection 
(1/2 point)

 Ears set appropriately

 Ears low set, posteriorly rotated

Pinna 
(1/2 point)

 Pinna flexible

 Pinna stiff

 Inspected Mouth

1 of 1 point

Frenulum 
(1/4 point)

 Frenulum intact

 Frenulum thick

Palate 
(1/4 point)

 Palate intact

 Palate open

Tongue 
(1/4 point)

 Tongue smooth

Zachary LaFontaine Visit Shadow health Objective data

 Tongue rough

Uvula 
(1/4 point)

 Uvula midline

 Uvula absent

 Inspected Skin

1 of 1 point

Color 
(1/8 point)

 Cyanosis

 Jaundice

 Pallor

 Congruent with genetic background

Texture 
(1/8 point)

 Smooth

 Rough

Temperature 
(1/8 point)

 Warm

 Cool

Skin Hydration 
(1/8 point)

 Elastic

 Tenting

 Sluggish turgor

Lesions 
(1/8 point)

 No visible lesions

 Laceration/wounds

 Erythema

 Ecchymosis

 Birthmark

 Discolorations

Mucous Membrane: Hydration 
(1/8 point)

 Moist

 Dry

Mucous Membrane: Appearance 
(1/8 point)

 Intact

 Cracked

 Blistered

Zachary LaFontaine Visit Shadow health Objective data

Mucous Membrane: Color 
(1/8 point)

 Pink

 Pale

 Erythematous

 Inspected Diaper Area

1 of 1 point

Inspect Skin Diaper Area 
(1/1 point)

 No lesions present

 Macerated

 Edema

 Erythema

 Inspected Genitalia

1 of 1 point

Appearance 
(1/5 point)

 Urethral meatus midline

 Hypospadias

 Ambiguous genitalia

Palpation 
(1/5 point)

 Testes present bilaterally

 Testes not palpable

Rugae 
(1/5 point)

 Smooth

 Rough

Masses 
(1/5 point)

 No masses

 Mass palpable

 Swelling

Circumcision 
(1/5 point)

 Circumcised

 Uncircumcised

 Assessed Musculoskeletal: Barlow and Ortolani

1 of 1 point

Barlow 
(1/2 point)

 Positive

 Negative

Ortolani 
(1/2 point)

 Positive

 Negative

 Assessed Eyes: Pupils

1 of 1 point

Shape 
(1/3 point)

 Round

Zachary LaFontaine Visit Shadow health Objective data

 Abnormal shape

Light Reaction 
(1/3 point)

 No reaction to light

 Reacts to light symmetrically

 Reacts to light asymmetrically

Opacity 
(1/3 point)

 Clear

 Cloudy

 Assessed Eyes: Red Reflex

1 of 1 point

Red Reflex 
(1/3 point)

 Absent

 Present

Color 
(1/3 point)

 Equal color bilaterally

 Unequal color bilaterally

Opacity 
(1/3 point)

 Opacity absent

 Opacity present

 Assessed Eyes: Tracking

1 of 1 point

Vision Screening 
(1/1 point)

 Follows object in both directions

 Does not follow object in both directions

Zachary LaFontaine Visit Shadow health Objective data

 Assessed Extremities

1 of 1 point

Movement 
(1/2 point)

 Moves all extremities

 Does not move all extremities

Symmetry 
(1/2 point)

 Movement symmetrical

 Movement asymmetrical

Zachary LaFontaine Visit Shadow health Objective data

 Assessed Grasp

1 of 1 point

Grasp 
(1/3 point)

 Intact

 Not Evident

Tone 
(1/3 point)

 Strong

 Weak

Symmetry 
(1/3 point)

 Symmetrical

 Asymmetrical

 Absent

 Assessed Moro Reflex

1 of 1 point

Moro Reflex 
(1/2 point)

 Normal Response

 Weak response

 Absent response

Hearing 
(1/2 point)

 Hearing intact

 Hearing absent

 Assessed Tonic Reflex

1 of 1 point

Neck Range Of Motion 
(1/2 point)

 Symmetrical

 Asymmetrical

 Absent

Tonic Reflex 
(1/2 point)

 Present

 Absent

Zachary LaFontaine Visit Shadow health Objective data

 Assessed Pulse

1 of 1 point

Pulse 
(1/2 point)

 Regular

 Irregular

Amplitude 
(1/2 point)

 Equal bilaterally

 0

 +1

 +2

 +3

 Assessed Rooting Reflex

1 of 1 point

Rooting Reflex 
(1/1 point)

 Normal response

 Weak response

 Absent response

 Assess Sucking Reflex

1 of 1 point

Sucking Reflex 
(1/2 point)

 Normal response

 Weak response

 Absent response

Tongue Range Of Motion 
(1/2 point)

 Normal response

 Absent response

Zachary LaFontaine Visit Shadow health Objective data

 Assessed Neurological: Stepping/Walking Reflex

1 of 1 point

Stepping Relfex 
(1/1 point)

 Present

 Absent

 Palpated Abdomen

1 of 1 point

Light Palpation 
(1/2 point)

 Soft

 Firm

 Distended

 Mass

 Bulges

Tenderness 
(1/2 point)

 Nontender

 Tender

 Palpated Fontanelles

1 of 1 point

Anterior 
(1/2 point)

 Sunken

 Flat

 Bulging

Posterior 
(1/2 point)

 Sunken

 Flat

 Bulging

Zachary LaFontaine Visit Shadow health Objective data

 Auscultated Abdomen

0.5 of 1 point

Appearance 
(No point)

 Protuberant

 Flat

 Scaphoid

Auscultation 
(1/2 point)

 Absent

 Hypoactive

 Normoactive

 Hyperactive

 Auscultated Heart

1 of 1 point

Rate 
(1/3 point)

 Regular Rate

 Irregular Rate

Rhythm 
(1/3 point)

 Regular rhythm

 Arrhythmia

Heart Sounds 
(1/3 point)

 S1

 S2

 S3

 S4

 Murmurs

 Auscultated Lungs

1 of 1 point

Appearance 
(1/3 point)

 Symmetrical chest rise

 Asymmetrical chest rise

Breath Sounds 
(1/3 point)

 Clear to auscultation

 Wheezing

 Stridor

 Grunting

 Absent

Respiratory Effort 
(1/3 point)

 Smooth, even respirations

 Nasal flaring

 Retractions

Zachary LaFontaine Visit Shadow health Objective data

Zachary LaFontaine Infant Well Visit Shadow health documentation

My Provider Notes

Student Documentation

Model Documentation

Subjective

Zachary LaFontaine Infant Well Visit Shadow health documentation

2 month old male infant today for child check. Birth information male infant born via vaginal delivery at 39 weeks gestation. Length-19”, Weight-7lbs 4 oz, APGAR 9@ 1 min, 10 @ 5 min. There were no birth complications. Here today accompanied by his mother. Medications: Currently not taking any medications, No known medication allergies Nutrition: Breastfeed 5-7 feeds/day about 10 min each breast, schedule varies by day due to mothers school schedule Elimination: Spitting-minimal, 5-6 wet diapers a day, usually 3 bowel movement per day soft, mustard yellow in nature Sleep: Sleeping about 16 hours on Mon-Wed-Fri, Unknown number of hours of sleep on Tuesday and Thursday as her mother cares for Zachary on these days while she is at school. He does wake up more frequently at night on Tuesday and Thursdays Development and behavior: Zachary LaFontaine Infant Well Visit Shadow health documentation Reports infant smiles, tracks objects with his eyes, coos, turns to noises and familiar sounds. Able to lift his head when on his tummy. Maternal Health: Reports a very busy schedule. Attends school two days a week and her mother helps care for Zachary when she is at school. Reports she does eat a healthy diet and drinks plenty of water. Does report insufficient sleep. Reported breasts feel full before feeding and don’t always feel empty after feeding. Denies any breast leaking. Safety: Car seat is rear facing in the back seat, Back to sleep on a cradleboard or in the bassinet in mothers bedroom, Daycare-not enrolled at this time, cared for at home by relatives. Zachary LaFontaine Infant Well Visit Shadow health documentation

Objective

Zachary LaFontaine Infant Well Visit Shadow health documentation

Vital signs: Length=55.2 cm, Weight=4.39 kg, Head circumference=38.1 cm, Temp=36.2C, Heart rate= 132/min, Resp=36 breaths/min General: Infant in mothers arms, calm and alert HEENT: Head: symmetrical, Anterior fontanelle smooth, soft, flat, Posterior fontanelle smooth, soft, flat thin hair Eyes: open spontaneously, lens clear, red reflex present, PERRL Ears: ears aligned with palpable fissures, pinna flexible, lobe formed appropriately, turns head towards sounds Nose: Nares pink, patent, thin white mucus present Mouth/Throat: Palate intact, tongue with full ROM, smooth, frenulum intact, uvula midline Neck: Neck with full ROM, lags when lifting body Resp: Symmetrical chest rise and fall, smooth even respirations, bilateral lungs clear to auscultation, CV: Regular rate and rhythm, S1S2 present, no murmurs, Pulse present, equal bilaterally Abd: Abdomen protuberant, soft, nontender, bowel sounds normoactive, umbilicus healed GU: Scrotum with smooth rugae, circumsized penis with urethral meatus midline, testes present bilaterally MSK: Bilateral extremities symmetrical, moves all extremities freely, Barlow and Ortolani negative. Neuro: Active, alert, sucking, rooting reflex intact, moro reflex intact, stepping reflex intact, tonic reflex intact and symmetrical, grasp reflex intact Skin: Warm, smooth, congruent with genetic background. Elastic turgor. No lesions noted, mucous membranes moist, pink and intact. diaper area without any rash. Hearing/Vision: Eyes track objects. Turns head to familiar voice Zachary LaFontaine Infant Well Visit Shadow health documentation

Assessment

Normal findings for a 2 months old male baby. Head with normal development, normal size, and growing speed. Well nurished. No abnormal findingds on cardiopulmonary systems. Ortho: Barlow and Ortolani were normal, no Signs pf hip problems. Moro reflex normal for the age. Zachary LaFontaine Infant Well Visit Shadow health documentation Milestones within age for normal development.

Well child check Feeding difficulties

Plan

Continue breastfeeding. Appointment in 2 months, unless needed before for abnormal findings. Monitor mother health, physical and mental. Vaccination as per CDC. Zachary LaFontaine Infant Well Visit Shadow health documentation

Surveillance for next visit Vitamin D drops 400 IU 1 drop daily Continue with breastfeeding, develop a structured feeding schedule and begin using breast pump in between feedings so you have milk to supplement your infant when you are at school. Consultation with a lactation specialist to improve feeding practices, develop appropriate feeding schedules and provide support. Never leave unattended, Continue with back to sleep, Vaccines administered today-HepB, RV, DTaP, PCV13, IPV and HiB. Your infant may be a little fussy today and develop a low grade fever. Notify the office for any high fevers, vaccine site reactions, rashes. Call 911 if develops difficulty breathing Return for weight check in 3-4 weeks and then for 4 month old well child visit Anticipatory Guidance: Social Language & Self Help: Will begin to turn head towards familiar voices. Will look to parent to reassure him when he is upset. He will begin to associate you as the person who consoles him when he is upset. Zachary LaFontaine Infant Well Visit Shadow health documentation. Verbal Language: Will begin making extended cooing sounds. Will become more organized. Gross Motor: Will begin to support self on elbow and wrists. Encourage tummy time to build upper body strength and neck strength. Will begin to roll from stomach to back Fine motor: Will begin to notice he has fingers and will grasp objects with his whole hand. Pa Zachary LaFontaine Infant Well Visit Shadow health documentationrent and family health: Make sure you have your postpartum check up. Take time to care for yourself. Infant behavior: Hold, cuddle, talk and sing to your infant. It is a good time to start reading to help with brain development. Pay attention to your infant’s cues for sleep. Keep a schedule. Tummy time throughout the day when awake. Find calming techniques he will respond to. Important to never shake or hit your baby. Nutrition: It is too early for any food other than breast milk. Anticipate 5-6 wet diapers a day and 3-4 stools per day. Continue your prenatal vitamin and a healthy diet. Safety: Continue with rear-facing infant seat in the backseat. Set your water heater to 120 degrees F. Do not leave your infant alone. As he begins to roll, you will need to keep a hand on him when on the changing table, etc. Zachary LaFontaine Infant Well Visit Shadow health documentation

Zachary LaFontaine Infant Well Visit Shadow health

TRANSCRIPT

Good morning. How are you?

Greet

02/18/22 7:58 PM EST

Hi.

you have a beautiful baby (No matching questions found.)

Question

02/18/22 7:58 PM EST

what brings you here? Zachary LaFontaine Infant Well Visit Shadow health

Question

02/18/22 7:59 PM EST

We’re here for Zachary’s wellness visit. It was hard to work it into our schedule, but I know it’s important.

I am glad you could make it.

Empathize

02/18/22 8:00 PM EST

I appreciate it.

How is Zachary doing?

Question

02/18/22 8:00 PM EST

Zachary is a very happy baby. He smiles quite a bit. It’s nice coming home from school or work to see him.

How old are you? (No matching questions found.)

Question

02/18/22 8:01 PM EST

where do you work? (No matching questions found.) Zachary LaFontaine Infant Well Visit Shadow health

Question

02/18/22 8:01 PM EST

who do you leave him with when you work? (No matching questions found.)

Question

02/18/22 8:02 PM EST

who do you leave him with when you work? (No matching questions found.)

Question

02/18/22 8:02 PM EST

it is important to interact with baby

Educate

02/18/22 8:03 PM EST

Ok, that sounds good.

How is he eating?

Question

02/18/22 8:03 PM EST

Zachary only gets breastmilk, no formula at all.

how many times a day does he eat? (Clarified to How often do you feed your son?.)

Question

02/18/22 8:03 PM EST

I try for 2-3 hours during the day and 3-4 at night. We don’t always manage it, though. (Clarified to how often I feed my son.)

how is he sleeping?

Question

02/18/22 8:04 PM EST

Zachary always has a hard time sleeping on nights I come home late, Tuesdays and Thursdays. It’s hard on me because I can barely get any sleep those nights, and I don’t get much as it is. I wake up early for class after taking care of Zachary all night. It’s a lot.

I understand it could be a lot, i am glad you are taking care of Zach

Empathize

02/18/22 8:06 PM EST

I appreciate that.

Zachary LaFontaine Infant Well Visit Shadow health

Zachary LaFontaine Infant Well Visit Shadow health

what are your goals for breastfeeding?

Question

02/18/22 8:31 PM EST

I want to only breastfeed Zachary. I know formula is an option, but that would be a last resort. I want to focus on giving my baby breast milk.

that is great. breast milk is the best for a baby

Educate

02/18/22 8:32 PM EST

I understand.

where your son sleep? (Clarified to Where does your son sleep?.) Zachary LaFontaine Infant Well Visit Shadow health

Question

02/18/22 8:32 PM EST

Zachary sleeps in a bassinet at night or sometimes in his cradleboard. He’s always swaddled and always on his back. I keep the bassinet empty and in my room, so I’m always nearby Zachary LaFontaine Infant Well Visit Shadow health. I’m really afraid of SIDS or anything like that, so I did a lot of reading on sleep safety. (Clarified to where my son sleeps.)

how is your son sleeping?

Question

02/18/22 8:33 PM EST

Zachary always has a hard time sleeping on nights I come home late, Tuesdays and Thursdays. It’s hard on me because I can barely get any sleep those nights, and I don’t get much as it is. I wake up early for class after taking care of Zachary all night. It’s a lot.

it is important sleep supervision for safety

Educate

02/18/22 8:34 PM EST

Good to know.

what do you know about developmental milestones? (No matching questions found.)

Question

02/18/22 8:34 PM EST

developmental milestones? (No matching questions found.)

Question

02/18/22 8:35 PM EST

milestones? (No matching questions found.)

Question

02/18/22 8:35 PM EST

milestones?any verbal language? (No matching questions found.)

Question

02/18/22 8:35 PM EST

any verbal language? (No matching questions found.)

Question

02/18/22 8:36 PM EST

does your son makes any sound? (Clarified to Does your son make gestures?.)

Question

02/18/22 8:36 PM EST

He squirms around a lot and smiles. [AUDIO COMING SOON] (Clarified to if my son makes gestures.) Zachary LaFontaine Infant Well Visit Shadow health

can your son make noise?

Question

02/18/22 8:37 PM EST

He coos and burbles. It’s pretty cute.

are you reading books? (No matching questions found.)

Question

02/18/22 8:38 PM EST

are you learning about kids? (No matching questions found.)

Question

02/18/22 8:38 PM EST

are you learning about your son? (No matching questions found.)

Question

02/18/22 8:38 PM EST

does your son follow sounds? (Clarified to Does your son track you with his eyes?.)

Question

02/18/22 8:39 PM EST

He does, yes. He also loves staring at strangers. He seems curious about everything. (Clarified to if my son follows me with his eyes.)

does your son follows the sound of your voice?

Question

02/18/22 8:39 PM EST

Zachary will look at me if I talk to him. Sometimes he’ll stare at me or make a little coo. [AUDIO COMING SOON]

are you depressed?

Question

02/18/22 8:40 PM EST

Well . . . I don’t know? I don’t think I’m technically depressed, but I’ve just been so busy and tired that I barely have time to reflect on myself like that. I feel overwhelmed. I don’t know how I am going to handle everything and raise Zachary. But I’ll figure it out. I have to. [AUDIO COMING SOON]

post partum depression is a frequent finding, please let us know if anything we can help with

Educate

02/18/22 8:41 PM EST

Alright, thanks.

 Inspected head circumference growth chart

Exam Action

02/18/22 8:41 PM EST

 Inspected weight and length growth chart

Exam Action

02/18/22 8:51 PM EST

 Inspected head circumference growth chart

Exam Action

02/18/22 8:57 PM EST

 Inspected nose

Exam Action

02/18/22 8:58 PM EST

 Inspected ears

Exam Action

02/18/22 8:59 PM EST

 Frenulum attached middle of mouth floor. Appropriate length and movements. Appears thin. Palate meets at the midline completely. Tongue appears smooth and uvula located at midline. Zachary LaFontaine Infant Well Visit Shadow health

Exam Action

02/18/22 8:59 PM EST

 Inspected ears

Exam Action

02/18/22 9:00 PM EST

 Frenulum attached middle of mouth floor. Appropriate length and movements. Appears thin. Palate meets at the midline completely. Tongue appears smooth and uvula located at midline.

Exam Action

02/18/22 9:00 PM EST

 Inspected skin

Exam Action

02/18/22 9:00 PM EST

 Inspected skin: diaper area

Exam Action

02/18/22 9:01 PM EST

 Inspected genitalia

Exam Action

02/18/22 9:01 PM EST

 Assessed Musculoskeletal Barlow and Ortolani

Exam Action

02/18/22 9:02 PM EST

 Assessed eyes: pupils

Exam Action

02/18/22 9:04 PM EST

 Assessed red reflex

Exam Action

02/18/22 9:05 PM EST

 Assessed Eye Tracking

Exam Action

02/18/22 9:05 PM EST

 Assessed extremities

Exam Action

02/18/22 9:05 PM EST

 Assessed grasp: Able to lift shoulders off table with expected head lag.

Exam Action

02/18/22 9:06 PM EST

 Assessed Moro Reflex: Infant briskly abducts arms and legs symmetrically, then brings legs up against trunk. Zachary LaFontaine Infant Well Visit Shadow health

Exam Action

02/18/22 9:06 PM EST

 Assessed Moro Reflex: Infant briskly abducts arms and legs symmetrically, then brings legs up against trunk.

Exam Action

02/18/22 9:06 PM EST

 Assessed Tonic Reflex and neck range of motion.

Exam Action

02/18/22 9:06 PM EST

 Assessed pulse

Exam Action

02/18/22 9:06 PM EST

 Assessed Rooting Reflex: Infant turns head in direction of stimulus and opens mouth.

Exam Action

02/18/22 9:07 PM EST

 Infant response with sucking motion. Tongue protrudes past lips.

Exam Action

02/18/22 9:07 PM EST

 Assessed neurological stepping/walking reflex

Exam Action

02/18/22 9:07 PM EST

 Palpated abdomen

Exam Action

02/18/22 9:08 PM EST

 Anterior fontanelle palpated is diamond-shaped, soft, flat, approximately 2-3 cm in width and 3-4 cm in length. Posterior fontanelle is triangle shaped 0.5-1 cm in size, soft, and flat.

Exam Action

02/18/22 9:08 PM EST

 Auscultated Upper Right Abdomen: Abdomen rounded, appropriate for age.

Exam Action

02/18/22 9:09 PM EST

 Auscultated Upper Left Abdomen: Abdomen rounded, appropriate for age.

Exam Action

02/18/22 9:09 PM EST

 Auscultated Lower Left Abdomen: Abdomen rounded, appropriate for age. Zachary LaFontaine Infant Well Visit Shadow health

Exam Action

02/18/22 9:09 PM EST

 Auscultated Lower Right Abdomen: Abdomen rounded, appropriate for age.

Exam Action

02/18/22 9:09 PM EST

 Auscultated Top Right Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action

02/18/22 9:10 PM EST

 Auscultated Top Left Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action

02/18/22 9:10 PM EST

 Auscultated Upper Left Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action

02/18/22 9:10 PM EST

 Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals. Zachary LaFontaine Infant Well Visit Shadow health

Exam Action

02/18/22 9:10 PM EST

 Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action

02/18/22 9:10 PM EST

 Auscultated Lower Left Chest: Apical pulse palpated reveals rate steady and regular intervals.

Exam Action

02/18/22 9:10 PM EST

 Auscultated Upper Upper Right Chest

Exam Action

02/18/22 9:10 PM EST

 Auscultated Upper Upper Left Chest

Exam Action

02/18/22 9:10 PM EST

 Auscultated Upper Right Chest

Exam Action

02/18/22 9:10 PM EST

 Auscultated Upper Left Chest

Exam Action

02/18/22 9:10 PM EST

 Auscultated Lower Left Chest

Exam Action

02/18/22 9:10 PM EST

 Auscultated Lower Right Chest

Exam Action

02/18/22 9:10 PM EST

 Auscultated Lower Right Back

Exam Action

02/18/22 9:11 PM EST

 Auscultated Lower Left Back

Exam Action

02/18/22 9:11 PM EST

 Auscultated Upper Left Back

Exam Action

02/18/22 9:11 PM EST

 Auscultated Upper Right Back

Exam Action

02/18/22 9:11 PM EST

 Auscultated Upper Upper Right Back

Exam Action

02/18/22 9:11 PM EST

 Auscultated Upper Upper Left Back Zachary LaFontaine Infant Well Visit Shadow health

Exam Action

02/18/22 9:11 PM EST