Chapter 11: The Endocrine System | Kathryn Noah's Chart Note

CHART NOTE

Patient Name: Noah, Kathryn
ID Number: 93654KN
Examination Date: February 12, 20xx

SUBJECTIVE
Kathryn is a 78-year-old patient who is here for a diabetic recheck. She rarely checks her blood sugars. She has not checked her sugar levels in the past 2 weeks and has lost 5–10 pounds since her last visit. Patient complains of numbness and tingling of the left great (big) toe with a foul-smelling discharge.

OBJECTIVE
She is inconsistent in taking her diabetic meds. BP is 140/98. Low-grade fever of 101. Eye exam is negative. Nose, mouth, neck, and thyroid exam are negative. Heart is without murmurs. Lungs are clear. Obese abdomen. Inflamed left great toe, bluish in color, with purulent discharge. The toe is cold to the touch with slight sloughing (falling off) of the skin.

ASSESSMENT
1. Gangrene of left great toe.
2. Type 2 diabetes, suboptimal control.
3. Obesity.

PLAN
Admit for amputation of left great toe due to gangrene.