24 Aug The student will be given a medical condition or disease. They will have to research it to come up with enough information to write a detailed note as described below. Must be in PQRRRST f
MA210 Syllabus www.mildred-elley.edu Page 12 of 15 Last Revised 01/2022 Curriculum Revised: 01/2022 Project The student will be given a medical condition or disease. They will have to research it to come up with enough information to write a detailed note as described below. Must be in PQRRRST format and have specific notes for each part of the acronym. Chief Complaint and PMH must add up to minimum of 55 words 1. Chief Complaint: Must be minimum of 30 words (abbreviation included) 2. Past Medical History: Must be a minimum of 25 words 3. Medications: Must have medications that are associated with your disease and the proper dosages and two others with the proper dosages that are associated with the PMH. 4. Allergies: Must have 4 allergies: a. 2 Medication b. 1 Environmental c. 1 Food You will be graded on: 1. Accuracy of the note. 2. Proper medications and dosages for the disease given. 3. Proper format. (PQRRRST)
Acute Appendicitis
Chart Note Project
On
ACUTE APPENDICITIS
Submitted By
…………………
Mildred Elley NYC Metro Campus
SPECIALIZED PROCEDURE
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.
