Determine the primary and secondary diagnosis from the informationprovided below:Outpatient Office V

Determine the primary and secondary diagnosis from the informationprovided below:Outpatient Office VisitPatient Case Number: OPOV04-Lampe, QuincyPatient Name: Quincy LampeDOB: 04-15-05Sex: MDate of Service: 03-25-XXPhysician: Stacey Torresi, MDHistory of Present Illness:Quincy presents today for a follow-up for his Type I diabetes. He has had DM forabout 5 years now and is accompanied by his mother and father who provided thehistory.Quincy’s mother reported that his interval history is notable for problems such aswidely fluctuating blood glucose levels, despite stable insulin doses, diet and lifestyle.Review of blood glucose log: Parents check Quincy’s blood glucose every night because they feel that he has hypoglycemia unawareness. With one exception, his blood glucose at night is always above 150 mg/di. His first morning blood glucose has been in excess of 200 mg/di for the past month. Mom increased his Levemir dose to 5 units at bedtime. He appears to be at target or below around early afternoon and before dinner.Review of Systems:Constitutional: no fatigue, inappropriate weight gain, weight lossHead: No headachesEyes: No vision concernsRespiratory: No cough, chest painAbdominal: No pain, diarrhea, constipation Genitourinary: No polyuria, nocturia, no nocturnal enuresis Neurologic: No decreased sensation in hands or feet. Musculoskeletal: No pain in feet, ingrown toenails Skin: No dry skin, injection pump site problems Psychological: No social, emotional or coping concernsEndocrine: No polydypsia, hypoglycemia unawarenessOther concerns: He complains of generally not feeling well even when his blood glucose is within expected range.MedicationsRespiratory: No cough, chest painAbdominal: No pain, diarrhea, constipation Genitourinary: No polyuria, nocturno nocturnal enuresis Neurologic: No decreased sensation in hands or feet.Musculoskeletal: No pain in feet, ingrown toenails Skin: No dry skin, injectionpump site problems Psychological: No social, emotional or coping concernsEndocrine: No polydypsia, hypoglycemia unawarenessOther concerns: He complains of generally not feeling well even when his bloodglucose is within expected range.Allergies: NKDAPast Medical History: DMIVitals: BP-120/58, Pulse-80, Ht-61.5″, Wt-105lbs, BMI-19.8Physical Examination General: alert and no distressHead: normocephalic, atraumaticEyes: sclerae white, pupils equal and reactiveEars: normal bilaterallyNose: nares patent with no flaring and no discharge, swelling or lesions notedMouth: no abnormalities and mucous membranes moist, no oral lesionsNeck: supple with no lymphadenopathy, thyromegaly, or massesLungs: clear to auscultation bilaterallyHeart: regular rate and rhythm, no murmurAbdomen: soft, nontender, bowel sounds presentExtremities: warm and dry, without abnormalities; fingertips appear healthyThyroid: thyroid is normal in size without nodules or tendernessTone: normal tone, bulk, and strengthSkin: normal and dryNeurological: Alert and oriented; no focal abnormalitiesFeet: Normal exam.Assessment/Plan:1. DMI2. Long term insulin use- increase Levemir to 6 units at night Health Science Science Nursing NURS 254 Share QuestionEmailCopy link Comments (0)

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