Question

A 32 year old male, mr. Douglas, is admitted for amputation of his left great toe

Documentation Exercise Scenario: Question 37 refers to this scenario. You are caring for Claudia White, a 36-year-old female patient with newly diagnosed diabetes mellitus type 2. She was admitted on April 2, 2022. Her date of birth is 05/14/1985. Her ID number is 2783465, and she is in Room 836. Today is April 4, 2022. You are preparing to teach her how to do finger stick blood sugar testing. At 11:20 a.m., you go to her room to show her how to check her blood sugar before meals. She is anxious and upset, saying that she doesn't like needles and she does not want to "stick" herself. You suggest that she just watch you do the test this time. She relaxes some and pays close attention. You explain each step as you perform it. She tells you that she is surprised that it did not hurt when you used the lancet device to make the puncture on her forearm. You explain that sometimes alternate sites are less painful than using the fingertips. Her blood sugar reading was 145 mg/dL. You explain that normally before a meal, the reading should be between 80 and 120. You also explain that the medication she has been started on will help lower her blood sugar, but that she must also make healthy food choices and avoid concentrated sugars. Ms. White tells you that she knows about diabetic diets because her father

Answer 1

RECIEVED THE PATIENT Mr.DOUGLAS,32YRS/MALE, ADMITTED FOR LEFT GREAT TOE AMPUTATION ON APRIL 2,2020 AND POSTED FOR SURGERY ON APRIL 3,2020. HOSPITAL ID NO-2783444

VITALS CHECKED AT 11:20AM AND NOTED TO BE STABLE- BP-120/80mm/hg GRBS-120mg/dl,PULSE-72/min. BLOOD INVESTIGATIONS SEND AS PER ORDER AND HISTORY NOTED; ON EXAMINATION OF RIGHT GREAT TOE DISCOLORATION (DARK) NOTED WITH REDUCED SENSTAION OF THE LEFT GREAT TOE AS COMPARED TO RIGHT GREAT TOE. CAPILLARY REFILLING FOUND TO BE REDUCED IN THE LEFT GREAT TOE INDICATING COMPROMISED VASCULARITY. HISTORY REGARDING ANY FEVER, SWELLING,DISCHARGE FROM GREAT TOE ASKED. NUTRITIONAL STAUS EVALUATED,WEIGHT ,HEIGHT AND BMI. PATIEDNT EDUCATED REGARDING PROPER DIET PLAN AND IMPORTANCE OF NUTRIENT RICH DIET FOR FASTER RECOVERY. HISTORY OF ANY PREVIOUS ILLNESS, HOSPITALISATION AND MEDICATONS IF ANY ASKED. PATIENT EDUCATED REGARDING THE PROCEDURE ASWELL AS RECOVERY POSTOPERATIVELY.PSYCHOLOGICAL STATUS ASSESED AND PROPER SUPPORTIVE ADVISES GIVEN. DOCTORS ORDERS CARRIED OUT. DRUG ADMINISTRATED ASPER ORDERS AND CONSENT AFETR EXPLAINING.

AT 4:30 PM VITALS CHECKED, VITALS CHECKED, BP-120/80mm/hg,GRBS-120mg/dl,PULSE-80/min. PATIENT SEEN COMFORTABLE AND RELAXED, DOCTORS ORDERS CARRIED OUT AS PER ORDER AND CONSENT AFTER EXPLAINING.