Chart Note Project
On
ACUTE APPENDICITIS
Submitted By
…………………
Mildred Elley NYC Metro Campus
SPECIALIZED PROCEDURE
MA 210 D 1
Spring 1 / 2020
Professor: Dr. Sameh Kelada
CHIEF COMPLAINT: Pain around umbilicus for 4 hours with fever.
PROVOCATION- Pain that worsens if she coughs.
QUALITY- Dull pain
REGION- Started around umbilicus, then moved to right lower quadrant
RELIEF- The pain is slightly relieved during rest and by analgesics.
RADIATION- There is no radiation
SEVERITY- Severe, 8 out of 10 in scale 1-10.
TIME- Started at 5 A.M. in the morning.
PAST MEDICAL HISTORY- History of colitis due high fiber diets in 2015,
Diverticulitis 2016,
History of abdominal surgery in 2014
Diabetes Mellitus, hypertension and coronary artery disease
MEDICATION
MEDICATION APPLICATION TO DISEASE
Ciprofloxacin, Metronidazole, Morphine
CORRECT DOSAGES
Ciprofloxacin 400 mg IV q12h plus
Metronidazole 500 mg IV q8h for 7-14 day
Morphine -IV (opioid-naïve patients): 2.5-5 mg q3-4hr PRN, infused over 4- 5minutes; dose range, 4-10 mg
OTHER MEDICATIONS ASSOCIATEDW WITH PMH PROPER DOSAGES
Lisinopril 10 mg once per day.
Simvastatin 20 mg once per day.
ALLERGIES
MEDICATION ALLERGIES: Penicillin, and sulpha.
ENVIRONMENTAL ALLERGIES: Dust.
FOOD ALLERGIES: Peanut.
