View Patient Profiles

Lewis, Joshua

MRN: 213014

Room: 416

DOB: 2/27/1993

Age: 32

Gender: Male

Allergies: amoxicillin (rash on trunk and extremities)

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Adult Medicine Unit
Scenario	Today, you are on rounds with the Internal Medicine team outside the room of a patient who was admitted from the emergency department for management of an acute asthma exacerbation.
Admission note taken on 10/19/25
CC	difficulty breathing
HPI	A patient with a history of asthma since childhood. Patient reports not requiring maintenance medications for some time. Patient reports needing to use Proventil inhaler periodically requiring several visits to MD. Patient presented to emergency room this afternoon after mowing lawn and experiencing an increased difficulty in breathing. Patient realized inhaler was empty and went to pharmacy for refill. Pharmacist immediately referred patient to the emergency room. Patient was unable to complete sentences and was tachypneic and diaphoretic. Patient is on day 3 of 7 of a prescription for sinusitis. In the emergency room, the patient received albuterol nebs X 3 and an injection of methylprednisolone 125 mg.
PMH	Asthma since childhood Chronic sinusitis - increased difficulty with sinuses in spring and fall resulting in sinus infections 2-3 x/year T & A at age 7
Social History	Tobacco: Smokes 1 pack of cigarettes a day X 20 years. Pt tried to quit smoking (cold turkey) one year ago and failed. Alcohol: Drinks 1-2 alcoholic beverages per day. Caffeine: 3-4 cups of coffee, 3 Cokes daily Occupation: Works as a construction worker. Status: Lives with wife and 2 small children. Pt has a large support system of friends and colleagues. Physical Activity: Active lifestyle includes golfing, softball and fishing. Pt reports lifestyle is not hampered by asthma. Diet: Does not follow any special diet.	Family History	Mother alive at age 57 with noncontributory history. Father alive at age 59 with history of hypertension and acute Ml. Two male siblings 26 years and 30 years in good health.
Vaccine History	None on file	Surgical History	None on file
Physical Exam	Gen: Pleasant male in obvious respiratory distress HEENT: Brown, purulent nasal discharge; sinus drainage noted in back of throat; complains of continued face pain, upper jaw tooth pain and headache Skin: Diaphoretic Neck: No JVD, lymphadenopathy, or thyromegaly Heart: Tachycardic; normal S1 and S2, no S3 or S4; no m/r/g Lungs: Expiratory wheezes Abdomen: Deferred GU: Deferred Extremities: WNL Neuro: A & O x 3

Clinical Laboratory Report

Test Name	10/20/25	10/19/25	Range
Sodium (Na⁺)	137	137	136-145 mEq/L
Potassium (K⁺)	4.8	4.9	3.5-5 mEq/L
Chloride (Cl^-)	110	113	98-106 mEq/L
Bicarbonate (HCO₃^-)	26	25	23-28 mEq/L
Urea nitrogen (BUN)	8	8	8-20 mg/dL
Creatinine	0.5	0.5	0.5-1.3 mg/dL
Glucose	85	85	70-115 mg/dL
Hemoglobin A1c	5.9	6	5.3-7.5 %
Calcium,Total	9.1	8.9	8.6-10.2 mg/dL
Phosphate	4.4	4.5	3-4.5 mg/dL
Magnesium	2.0	2.1	1.6-2.6 mEq/L
Protein, total	6.8	7	5.5-9 g/dL
Albumin	4.1	4.2	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	14	13	10-40 units/L
Aminotransferase,alanine (ALT)	18	17	10-40 units/L
Lactic dehydrogenase (LDH)	92	92	80-225 units/L
Alkaline phosphatase	73	73	30-120 units/L
Bilirubin, Total	0.6	0.6	0.3-1 mg/dL
Leukocytes (WBC)	6.7	6.9	4.5-11 x10³/mcL
Red blood cells (RBC), Male	4.2	4.2	3.8-5.1 x10⁸/mcL
Hemoglobin, Male	16	16.5	14-18 g/dL
Hematocrit, Male	45	44.1	42-50 %
Mean corpuscular hemoglobin (MCH)	29	29	27-33 picogram
Mean corpuscular volume (MCV)	90	87	76-100 mcm³
Platelets	193	187	150-450 x10³/mcL
International normalized ratio (INR)	1	1	0.8-1.2
Prothrombin time (PT)	9.9	9.7	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	29	29	25-35 sec

Additional Labs:	None
Cultures:	None
Imaging Studies:	None

Vital Sign	10/20/25 07:15	22:32	17:41	10/19/25 09:47
Height (cm)	180			180
Weight (kg)	84			85
Body Temperature (°C)	37.0	37.1	36	37.1
Blood Pressure (mmHg)	128 / 72	120/74	121/71	120/73
Heart Rate (bpm)	95	118	118	120
Respiratory Rate (bpm)	18	24	24	25
Oxygen Saturation (%)	94	89	89	89

Current Orders

DRUG	DOSE	FREQ & TIME	PRN?

USE	START DATE	STOP DATE	NOTES
			Wean as air exchange improves

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

DRUG	DOSE	FREQ & TIME	PRN?

CONC	VOL	SOLN	RATE

USE	START DATE	STOP DATE	NOTES

Medication
History

Pt reports several exacerbations of asthma per year requiring > 1 Proventil inhaler refill per month
Three oral steroid bursts in past 12 months

Home Medication List: verified by pharmacy on admit (10/19/25)

Patient Name: Lewis, Joshua Date of Birth: 2/27/1993 Room#: 416	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	NOTES	MED REC ACTION
Ciprofloxacin 400 mg tablet	1 PO BID x7 days	no	on day 3 of 7 for sinusitis
Albuterol HFA 90 mcg/act Oral Inhaler	2 puffs PO PRN	yes, SOB	uses 2 inhalers per month
Acetaminophen 325 mg tablet	1-2 PO PRN	yes, HA	uses once every 1-2 weeks
				Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication	10/20/25	10/19/25
Albuterol Sulfate 0.083% 2.5 mg/3 mL NEB Q2H		5:50 7:19 9:53 11:22 13:32 15:47 17:20 19:31
Ciprofloxacin 400 mg IV Q12H Rate: 200 mL/hr		9:29 21:15
Methylprednisolone Sodium Succinate 40 mg IV Q6H Rate: push over 5 minutes		6:57 12:25 18:43 23:40

Clinical Notes

Impression/Plan
1. Admit to hospital for management of acute asthma exacerbation
2. Manage with albuterol, steroids, antibiotics for sinus infection

Admission Orders:
1. Admit to internal medicine service
2. Regular diet
3. Vital signs Q 2 hr
4. Meds:
- Albuterol neb Q2h
- Solu-Medrol 40 mg IV Q6h
- Cipro 400mg IV Q12h

Dr. Samuel Bernstein

Medication Discharge Orders

Hospital Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent

Previous Home Medications
Medication	Instructions	Comments	Continue	Modify	Discontinue	New Rx sent

Discharge Planning - Medication List and Instructions

Patient Name:
Admission Date:	Discharge Date:	Service:
Principle Diagnosis on Admission:
Secondary Diagnosis:
Allergies:

Medications ADDED this visit: (begin taking these)	Medications CHANGED this visit: (modify what you were taking)	Medications STOPPED this visit: (stop taking these)

Final Discharge Medication List
Medication/Route/Dosage/Frequency/Duration	Comments	Morning	Afternoon	Evening	Bedtime










As Needed Medications

Medication Reconciliation - Finalized Medication List

Patient Name: Lewis, Joshua

Date of Birth: 2/27/1993

Room: 416

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	180 cm
Actual Body Weight (ABW)	84 kg
Ideal Body Weight (IBW)	75.3 kg
ABW % of IBW	112 %
Adjusted Body Weight (AjBW)	78.8 kg
Body Surface Area (BSA)	2.05 m²
Body Mass Index (BMI)	25.9 kg/m²