Musculoskeletal Shoshanna Tillman Follow Up Sick Visit Shadow Health Treatment Plan
Problem Selection
9 out of 9
Primary Diagnosis
Review your answers for the Problem Selection activities. Y ou receive one point for each correct diagnosis, and one point for each correct evidence linked to a correct diagnosis. If there are multiple correct diagnoses, you will also receive a point for correctly selecting which diagnosis is the primary diagnosis.
Learner Selection Model Documentation Diagnosis: Joint pain Identified as primary
Evidences: Bilateral pain Pain not associated with trauma Tenderness with palpation
Learner Rationale:
The patient complains
of joint and body pain
Score: 5 out of 5 Diagnosis: Joint pain
Primary: Yes
Evidences:
Bilateral pain
Pain not associated with trauma
Tenderness with palpation
Model Rationale:
At this point in the diagnostic process, you can only provide Mrs. Tillman with preliminary diagnoses. In order to determine a definitive diagnosis, more diagnostic testing is required. In primary care, it is common to have multiple concerns in one visit. These two diagnoses may be related or are two unrelated situations, nonetheless, each diagnosis requires individual diagnostic investigation. Mrs. Tillman’s primary diagnosis is joint pain, while her secondary diagnosis is fatigue. The preliminary diagnosis of joint pain is supported by the evidence collected in the physical exam and reported by Mrs. Tillman: tenderness with palpation, pain not associated with trauma, and bilateral pain Musculoskeletal Shoshanna Tillman Follow Up Sick Visit
Shadow Health Treatment Plan. The secondary diagnosis of fatigue is supported by the evidence reported by Mrs. Tillman: an unusual lack of
energy, feeling tired, and having difficulty completing tasks due to feeling tired. When making a disease diagnosis, it is important to note that disease diagnosis documentation is permanent in the patient’s records and cannot be undone. Therefore, if you do not have the evidence and diagnostic testing to support a disease diagnosis it is best to collect more data before determining a definitive diagnosis, even if This study source was downloaded by 100000870127142 from CourseHero.com on 08-26-2023 23:39:07 GMT -05:00
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Musculoskeletal Shoshanna Tillman Follow Up Sick Visit Shadow Health Treatment Plan
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