Primary Diagnosis

Primary Diagnosis: Pre-Participation Sports Physical
– Identified as primary
– Evidences:
– Samantha reports the reason for her visit is a sports physical
– Score: 3 out of 3

– Additional 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

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Plan of Care

– Pharmacological Intervention
– Selected: No
– Recommended: No
– Learner Rationale: No disease or problem was indicated by the patient
– Score: 1 out of 1

– Non-Pharmacological Intervention
– Selected: Yes
– Recommended: Yes
– Learner Rationale: You should discuss with the patient about her food and dieting habits.
– Score: 1 out of 1

Samantha Monroe shadow health Subjective data Collection

– Educate Patient
– Selected: Yes
– Recommended: Yes
– Learner Rationale: Patient should be taught to take care of her own health.
– Score: 1 out of 1

– Preventive Screening and Intervention
– Selected: No
– Recommended: No
– Learner Rationale: Samantha already got preventive screening during her 134-year old well visit.
– Score: 1 out of 1

– Diagnostic Testing: Labs and Imaging
– Selected: No
– Recommended: No
– Learner Rationale: No conditions were indicated that would require testing.
– Score: 1 out of 1

– Referral of Care
– Selected: No
– Recommended: No
– Learner Rationale: 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.
– Score: 1 out of 1

– Continued Care and Follow-up
– Selected: Yes
– Recommended: 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

Non-Pharmacological Intervention

– Discuss Life-threatening Health Problems
– Selected: Yes
– Recommended: Yes
– Learner Rationale: Given Samantha’s lack of knowledge around the consequences of eating disorders, it is critical she understands the long-term consequences of poor nutrition.
– Score: 1 out of 1

– Limiting Media Intake
– Selected: Yes
– Recommended: Yes
– Learner Rationale: 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.
– Score: 1 out of 1

– Discussing Caloric Intake Tracking
– Selected: No
– Recommended: No
– Learner Rationale: Given best practices and the details of Samantha’s case, this is an inappropriate intervention.
– Score: 1 out of 1

– Educate on Identifying Problematic Eating Behaviors
– Selected: No
– Recommended: No
– Learner Rationale: Given best practices and the details of Samantha’s case, this is an inappropriate intervention.
– Score: 1 out of 1

– Increase Knowledge of Coping Mechanisms
– Selected: Yes
– Recommended: Yes
– Learner Rationale: Given Samantha’s poor body image, desire to lose weight, and her tendency to compare herself to her peers, it is critical she develops positive coping mechanisms to build a more neutral, if not positive, approach to her body.
– Score: 1 out of 1

– Informing about Overcoming Body Issues
– Selected: No
– Recommended: No
– Learner Rationale: Given best practices and the details of Samantha’s case, this is an inappropriate intervention.
– Score: 1 out of 1

Education

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

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

Model Response:
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. 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.

Discussing Limiting Media Intake:
In your own words, discuss limiting media intake with Samantha and Jackie.

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

Model Response:
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. 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.

Increasing Knowledge of Coping Mechanisms:
In your own words, discuss increasing knowledge of coping mechanisms with Samantha and Jackie.

Learner Response:
You can try journalling, relaxation and stress management techniques, and affirmations.

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Model Response:
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.

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.

Additional Diagnosis