Chapter 2: The Integumentary System | Kate Stephano's Chart Note

CHART NOTE

Patient Name: Stephano, Kate
ID Number: 96453
Examination Date: January 23, 20xx

SUBJECTIVE
Kate was seen today for complaints of red and swollen, right great left toe. Patient denies injury. She is extremely anxious about the appearance of her toe.

OBJECTIVE
Examination reveals erythematous right great toe with purulent (pertaining to pus) drainage around the nail bed. The nail is thickened and appears to be mycotic in nature. It involves the entire nail plate.

ASSESSMENT
Onychomycosis

PLAN
Onychectomy. This is deferred due to patient anxiety and her desire to discuss this plan with her parents. Will follow up with phone call on how she wants to proceed.