Medical Record For
Lindsay Smith
Patient Information
Lindsay Smith
DOB:
5/25/1975
Sex:
Female
Gender Idenity:
Female
MRN:
843203
Weight:
155 lbs or 70.31 kg
Admitting Diagnosis:
Leiomyoma of uterus (uterine fibroids), anemia
Admitting Physician:
Michael Stark, M.D.
Past Medical History
Allergies
Tree nuts (Reaction: anaphylaxis)
Medical Problems
Leiomyoma of uterus (uterine fibroids), anemia
Surgical History
N/A
Social History
Divorced. Lives with her boyfriend in a condo building. Denies smoking or drug use. Drinks a glass of wine with dinner most nights. Works as a school counselor at the local high school. Has one adult child, Ben.
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 1100 | Michael Stark, M.D. | 49yo female, AAOx4, presented this morning for hysterectomy for treatment of painful leiomyoma of the uterus, aka uterine fibroids). The patient’s pre-op workup was complete without concerns. Patient tolerated procedure without complication. Admitted to medical surgical unit for observation. Monitor for pain, follow post op anticoagulation protocol. |
Vital Signs
| Time | 1100 |
|---|---|
| Heart Rate | 82 |
| Blood Pressure | 132/86 |
| Respiratory Rate | 16 |
| Pulse Ox | 98% on Room Air |
| Temperature | 100 F Oral |
| Pain | 5/10 |