Evans. Week6. soap - Patient Michael CC Pts mom states that...

Patient: Michael
CC: “Pts’ mom states that he is unusually tired.”
HPI: Complaints for a few weeks. Generalized location. Complaints of being unusually tired,
worsening cold, no energy, loss of appetite, weight loss, always thirsty, bed wetting, sleeping
more, dizzy, not wanting to play outside, and unable to keep up with kids in gym class.
Current Medications : Daily multivitamin
Allergies: Penicillin
PMHx: Rash from PCN allergy. Sleeps 8-10 hours/night. Immunization up to date.
Fam Hx: Parents and siblings are in good health, MGM: HTN and hyperlipidemia. MGF: HTN
and hyperlipidemia. Paternal grandparents deceased: PGM: brain Ca, PGF: leukemia
Social Hx: Good student, oldest of four children. Lives with parents, grandparents and siblings.
Have 2 dogs and a cat.
ROS:
NO SUBJECTIVE DATA GIVEN.
O.
Diagnostics:
Labs: CBC : WBC 7, Hgb 14 Hct 40 RBC 4.3 MCV 78 MCHC 34 RDW 11.5
Fasting glucose 136 mg/dL
TSH: 2.6 mIU/L ree T4 15 pmol/L
VS: 98.2, 65, 16, 110/70; weight 78lbs, height 4ft, BMI 23.8
RBC, T4 and MCV are low.
Pt is alert, and cooperative, appears tired and distracted.
CONSTITUTIONAL: No fever.
HEENT: Normocephalic head. Thick hair distribution and even throughout scalp. Eyes:
Conjunctiva white, sclera clear, PERRLA, EOMs intact. Ears, Nose Throat: tympanic membrane
gray and intact with light reflex noted. Pinna and tragus non-tender. Nares patent without
exudate. Sinuses nontender to palpation. Throat: Oropharynx dry, no lesions or exudate. Tonsils
¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No cervical
lymphadenopathy or tenderness noted. Thyroid midline, small, firm without palpable masses.
SKIN: color is pale pink, no cyanosis or pallor. Skin cool, dry and intact. Poor turgor. No moles
or skin changes.
CARDIOVASCULAR: CV: Heart S1 and S2 noted, RRR, no murmurs noted. PMI at 5 th ICS.
Peripheral pulses equally bilaterally.

RESPIRATORY: Lung clear to auscultation bilaterally. Respirations unlabored.
GASTROINTESTINAL: Abdomen round, soft, with hypoactive bowel sounds noted. No
organomegaly noted.
MUSCULOSKELETAL: Reflexes WNL. Gait steady.
A.
Diagnosis
Diabetes mellitus type 1 (ICD-10: E10) Diabetes mellitus, type 1 (DM1; formerly called
insulin-dependent diabetes mellitus or juvenile-onset diabetes) is a chronic, life-threatening
metabolic disorder characterized by severe insulin deficiency as a result of autoimmune
destruction of insulin-producing pancreatic β-cells (Schub & Cabrera, 2016). The destruction of
β-cells usually occurs abruptly during childhood, adolescence, or young adulthood, but
autoimmune destruction of β-cells can also occur later in life (e.g., latent autoimmune diabetes of
adulthood) (Schub & Cabrera, 2016). DM1 is thought to occur in genetically susceptible
individuals when they are exposed to environmental factors (e.g., certain viruses) that trigger a
dysfunctional immune response (Schub & Cabrera, 2016). S/S: clinical presentation usually
includes sudden polydipsia (i.e., abnormally increased thirst), polyuria (i.e., abnormally
increased urine output), unexplained weight loss, dehydration, and fatigue (Schub & Cabrera,
2016). The rationale for this diagnosis is Michael presentation of all of the above symptoms.