Medical Record For
Mona Morales

Patient Information

Name
Mona Morales
DOB:
5/14/1997
Sex:
Female
Gender Identity:
Woman
MRN:
843201
Weight:
150 lbs or 68.04 kg
Admitting Diagnosis:
UTI Evaluation
Admitting Physician:
Sam Lee, M.D.

Past Medical History

Allergies

Sulfa drug (severe rash)

Medical Problems

No significant past medical history

Surgical History

Wisdom teeth removal at age 17

Social History

Married and lives with spouse of 5 years. Works as an administrative assistant for a small local business.

Provider Notes

Time Provider Notes
0830 Michael Stark M.D. Patient presented to the emergency department complaining of frequent urination and increase thirst over the past week. She reports she feels increased pressure when she needs to void, but she attributes that to her pregnancy. She is concerned that she may have a UTI. She is G0 P1, and she is about 22 weeks pregnant. She has been admitted for UTI evaluation. Will also consult OB.

Vital Signs

Time 0800
Heart Rate 100 bpm
Blood Pressure 130/76 mmHg
Respiratory Rate 20 breaths/min
Temperature 99 F
Pulse Oximetry 99%
Oxygen in Liters On Room Air
Pain 0/10