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Determine the primary and secondary diagnosis.

Determine the primary and secondary diagnosis.

Essentials of Pharmacology for Health Professions
Essentials of Pharmacology for Health Professions
7th Edition
ISBN:9781305441620
Author:WOODROW
Publisher:WOODROW
Chapter19: Analgesics, Sedatives, And Hypnotics
Section: Chapter Questions
Problem 9CRQ
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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
Transcribed Image Text:... 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
Transcribed Image Text:..* 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.

 

 

 

 

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