Get Answer: Determine Primary Secondary Question Guide

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Original Question

Determine the primary and secondary diagnosis from the information provided below: Outpatient Office Visit Patient Case Number: OPOV04-Lampe, Quincy Patient Name: Quincy Lampe DOB: 04-15-05 Sex: M Date of Service: 03-25-XX Physician: Stacey Torresi, MD History of Present Illness: Quincy presents today for a follow-up for his Type I diabetes. He has had DM 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. 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 loss Head: No headaches Eyes: No vision concerns Respiratory: No cough, chest pain Abdominal: 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 concerns Endocrine: No polydypsia, hypoglycemia unawareness Other concerns: He complains of generally not feeling well even when his blood glucose is within expected range. Medications Respiratory: No cough, chest pain Abdominal: No pain, diarrhea, constipation Genitourinary: No polyuria, noctur 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 concerns Endocrine: No polydypsia, hypoglycemia unawareness Other concerns: He complains of generally not feeling well even when his blood glucose is within expected range. Allergies: NKDA Past Medical History: DMI Vitals: BP-120/58, Pulse-80, Ht-61.5″, Wt-105lbs, BMI-19.8 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 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 Extremities: warm and dry, without abnormalities; fingertips appear healthy Thyroid: thyroid is normal in size without nodules or tenderness Tone: normal tone, bulk, and strength Skin: normal and dry Neurological: Alert and oriented; no focal abnormalities Feet: Normal exam. Assessment/Plan: 1. DMI 2. Long term insulin use- increase Levemir to 6 units at night

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