Determine the primary and secondary diagnosis. ...Outpatient Office VisitPatient Case Number: OPOV04-Lampe, QuincyConstitutional: no fatigue, inappropriate weight gain, weight lossPatient Name: Quincy LampeDOB: 04-15-05Sex: MHead: No headachesDate of Service: 03-25-XXPhysician: Stacey Torresi, MDEyes: No vision concernsRespiratory: No cough, chest painAbdominal: No pain, diarrhea, constipation Genitourinary: Nopolyuria, nocturia, no nocturnal enuresis Neurologic: NoHistory of Present Illness:Quincy presents today for a follow-up for his Type I diabetes. Hehas had DMI for about 5 years now and is accompanied by hismother and father who provided the history.Quincy's mother reported that his interval history is notablefor problems such as widely fluctuating blood glucose levels,despite stable insulin doses, diet and life style.decreased sensation in hands or feet.Musculoskeletal: No pain in feet, ingrown toenails Skin: No dryskin, injection or pump site problems Psychological: No social,emotional or coping concernsEndocrine: No polydypsia, hypoglycemia unawarenessOther concerns: He complains of generally not feeling well evenwhen his blood glucose is within expected range.blood glucose log: Parents check Quincy's bloodglucose every night because they feel that he has hypoglyce-mia unawareness. With one exception, his blood glucose atnight is always above 150 mg/di. His first morning bloodglucose has been in excess of 200 mg/di for the past month.Mom increased his Levemir dose to 5 units at bedtime. HeReviewMedicationsMedicationDispenseSigWill use one with each injection with flex pen-mayneed up to 5 dailyTake 1 tablet by mouth every 8 hours as neededInsulin pen needle150 eachZofran5 tabletsfor nauseaappears to be at target or below around early afternoon andbefore dinner.UrineUse as directed if blood glucose is above 250 mg/dl 100 cachglucose-ketones testLevemirInject 5 units into the skin nightly15mLInject into skin prior to meals-may use up to 25units in divided doses dailyNovolog15mLReview of Systems:10:32 AM2/9/2022 ..* EGlucose test strips Use to test blood glucose up to 10 times a dayLancetsBlood glucosecalibration300 each300 eachExtremities: warm and dry, without abnormalities; fingertipsUse new lancet with each testappear healthyThyroid: thyroid is normal in size without nodules or tendernessTone: normal tone, bulk, and strengthSkin: normal and dryTest for strip quality1 cachGlucagon(emergency)Inject 1 mL into the skin as needed. Use as directedfor unconsciousness low blood sugar orhypoglycemic seizure2 eachAllergies: NKDANeurological: Alert and oriented; no focal abnormalitiesFeet: Normal exam.Past Medical History: DMIAssessment/Plan:1. DM IVitals: BP-120/58, Pulse-80, Ht-61.5", Wt-105lbs, BMI-19.82. Long term insulin use- increase Levemir to 6 units at nightPhysical 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 orElectronically Signed By: Stacey Torresi, MDCopyright © 2020 by The American Health Information Management Association. All Rights Reserved.lesions notedMouth: no abnormalities and mucous membranes moist, no orallesionsNeck: supple with no lymphadenopathy, thyromegaly, or massesLungs: clear to auscultation bilaterallyHeart: regular rate and rhythm, no murmurAbdomen: soft, nontender, bowel sounds presentEnd of document1032 AM2/9/2022

Answered: Determine the primary and secondary…

Phlebotomy Essentials

6th Edition

ISBN:9781451194524

Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Chapter1: Phlebotomy: Past And Present And The Healthcare Setting

Section: Chapter Questions

Problem 1SRQ

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Related questions

Question

Determine the primary and secondary diagnosis.

...
Outpatient Office Visit
Patient Case Number: OPOV04-Lampe, Quincy
Constitutional: no fatigue, inappropriate weight gain, weight loss
Patient Name: Quincy Lampe
DOB: 04-15-05
Sex: M
Head: No headaches
Date of Service: 03-25-XX
Physician: Stacey Torresi, MD
Eyes: No vision concerns
Respiratory: No cough, chest pain
Abdominal: No pain, diarrhea, constipation Genitourinary: No
polyuria, nocturia, no nocturnal enuresis Neurologic: No
History of Present Illness:
Quincy presents today for a follow-up for his Type I diabetes. He
has had DMI for about 5 years now and is accompanied by his
mother and father who provided the history.
Quincy's mother reported that his interval history is notable
for problems such as widely fluctuating blood glucose levels,
despite stable insulin doses, diet and life style.
decreased sensation in hands or feet.
Musculoskeletal: No pain in feet, ingrown toenails Skin: No dry
skin, injection or pump site problems Psychological: No social,
emotional or coping concerns
Endocrine: No polydypsia, hypoglycemia unawareness
Other concerns: He complains of generally not feeling well even
when his blood glucose is within expected range.
blood glucose log: Parents check Quincy's blood
glucose every night because they feel that he has hypoglyce-
mia 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
Review
Medications
Medication
Dispense
Sig
Will use one with each injection with flex pen-may
need up to 5 daily
Take 1 tablet by mouth every 8 hours as needed
Insulin pen needle
150 each
Zofran
5 tablets
for nausea
appears to be at target or below around early afternoon and
before dinner.
Urine
Use as directed if blood glucose is above 250 mg/dl 100 cach
glucose-ketones test
Levemir
Inject 5 units into the skin nightly
15mL
Inject into skin prior to meals-may use up to 25
units in divided doses daily
Novolog
15mL
Review of Systems:
10:32 AM
2/9/2022

..* E
Glucose test strips Use to test blood glucose up to 10 times a day
Lancets
Blood glucose
calibration
300 each
300 each
Extremities: warm and dry, without abnormalities; fingertips
Use new lancet with each test
appear healthy
Thyroid: thyroid is normal in size without nodules or tenderness
Tone: normal tone, bulk, and strength
Skin: normal and dry
Test for strip quality
1 cach
Glucagon
(emergency)
Inject 1 mL into the skin as needed. Use as directed
for unconsciousness low blood sugar or
hypoglycemic seizure
2 each
Allergies: NKDA
Neurological: Alert and oriented; no focal abnormalities
Feet: Normal exam.
Past Medical History: DMI
Assessment/Plan:
1. DM I
Vitals: BP-120/58, Pulse-80, Ht-61.5", Wt-105lbs, BMI-19.8
2. Long term insulin use- increase Levemir to 6 units at night
Physical Examination General: alert and no distress
Head: normocephalic, atraumatic
Eyes: sclerae white, pupils equal and reactive
Ears: normal bilaterally
Nose: nares patent with no flaring and no discharge, swelling or
Electronically Signed By: Stacey Torresi, MD
Copyright © 2020 by The American Health Information Manage
ment Association. All Rights Reserved.
lesions noted
Mouth: no abnormalities and mucous membranes moist, no oral
lesions
Neck: supple with no lymphadenopathy, thyromegaly, or masses
Lungs: clear to auscultation bilaterally
Heart: regular rate and rhythm, no murmur
Abdomen: soft, nontender, bowel sounds present
End of document
1032 AM
2/9/2022

Expert Solution

Step 1

Introduction-

Diabetes types is also known as Juvenile diabetes or Insulin dependent diabetes. Diabetes type I is a chronic condition in that pancreas is not producing enough insulin and due to the deficiency of insulin, sugar will not be uptake by the cells.

Diabetes is a chronic metabolic disorder in that blood sugar level is increases.

Insulin- Insulin is a hormone released by the beta cells of pancreas, which regulate the sugar and helps in uptake of sugar by cells.

Diabetes type I- It is also called a insulin dependent diabetes, because insulin production is affected by the autoimmune damage of beta cells of pancreas. This occurs before the age of 40 years.

Causes-

Autoimmune dysfunction.
Dietary factors like low vitamin D consumption, early complimentary feeding with high fats.
Race
Geographic area

Sign and symptoms-

There are 3 Ps which indicate the diabetes-

1) Polyuria- Excessive urination.

2) Polyphagia- Excessive hunger

3) Polydipsia- Excessive Thrust

other than that-

Nocturia
weight loss
Fatigue
Blurred vision
Numbness
skin itchining
irritability

Diagnostic test-

Blood monitoring
Oral glucose tolerance test
Glycosylated hemoglobin (A1C) test

Treatment -

Administration of Insul-
Healthy Life style-
Patient with diabetes should follow the healthy and nutritional diet, with low sugar content.
Physical Activity- Regular exercise will help the patient. it will help in maintaining the blood sugar level.