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LeBlanc, Remi

MRN: 283714

Room: Exam #1

DOB: 2/17/2001

Age: 24

Gender: Female

Allergies: NKDA, dust mite antigen

Admit Notes

Clinical Notes

Vitals

Labs, Cultures, Imaging

Clinical Calculators

MAR

Current Orders

Home Med List

Med Reconciliation

Discharge Planning

Setting	Outpatient Internal Medicine Asthma Clinic
Scenario	Patient was referred to the internal medicine asthma clinic for a follow-up evaluation of asthma therapy.
Admission note taken on 10/19/25
CC	tired to due frequent awakenings, dark circles under the eyes
HPI	RL was first diagnosed with asthma a little over one year ago just prior to starting college. She was admitted 2 months ago to the emergency department for an acute asthma exacerbation (her first) where she was treated with oral prednisone and albuterol. She was released from the emergency room after two hours of therapy with a five-day course of oral prednisone, as needed albuterol and a prescription for inhaled fluticasone. She followed up with her primary care physician on last month and at that time, she was given a peak flow monitor and told to monitor her peak expiratory flow rate every morning. She returned to her primary care physician for follow-up one month later with no improvement in peak expiratory flow rate and was referred to the internal medicine asthma clinic for evaluation. In clinic today, she has no specific complaints, but does state that she wakes up 2-3 times a week at night trying to catch her breath. She has been using her albuterol one to two times a day because it makes her feel better.
PMH	Allergic Rhinitis for 12 years Gastroesophageal Reflux Disease for 4 years Hypertension for 2 years Asthma for 1 year
Social History	Tobacco: Denies ETOH: Denies Illicit Drugs: Denies Caffeine: 2-4 diet cokes per day Occupation: College student Status: Single Children: none Physical Activity: Somewhat limited due to shortness of breath with exercise Diet: No limits, eats what she wants. Living arrangements: Lives alone in a two bedroom wood frame house on a concrete slab. The patient does not have any pets.	Family History	Father: Age 49 (Living), Hypertension, Dyslipidemia, Allergic Rhinitis, Obesity Mother: Age 48 (Living), Depression Sister: Age 18, (Living), Allergic Rhinitis
Vaccine History	None	Surgical History	None
Physical Exam	General: Female patient who looks her age and is in no apparent distress. She appears tired and has allergic shiners. Skin: Normal HEENT: Pupils equally round, 4.5mm, reactive to light and accommodation. Tympanic membranes are intact. Nasal mucous membranes are pale and swollen with no epistaxis. No nasal polyps. There is no tenderness over the frontal and maxillary sinuses, and the throat is normal. Neck: Normal, no lymphadenopathy or thyromegaly. Chest: slight bilateral wheezes scattered over all lung fields, no rales or rhonchi. Breast: Deferred Heart: Regular rate and rhythm, no gallops, murmur or rub Abdomen: Soft, non-tender, bowel sounds (+) Genitourinary/Rectal: Deferred Extremities: No clubbing, cyanosis or edema, pulses 2 plus throughout. Neurologic: Alert and oriented to person, place and time. Cranial nerves II-XII intact, deep tendon reflexes 2 plus throughout.

Clinical Laboratory Report

Test Name	10/19/25	08/20/25	Range
Sodium (Na⁺)	141	140	136-145 mEq/L
Potassium (K⁺)	4.1	3.6	3.5-5 mEq/L
Chloride (Cl^-)	101	103	98-106 mEq/L
Bicarbonate (HCO₃^-)	24	28	23-28 mEq/L
Urea nitrogen (BUN)	12	16	8-20 mg/dL
Creatinine	0.8	0.7	0.5-1.3 mg/dL
Glucose	89	82	70-115 mg/dL
Hemoglobin A1c	5.8	5.7	5.3-7.5 %
Calcium,Total	8.7	8.9	8.6-10.2 mg/dL
Phosphate	3.6	3.8	3-4.5 mg/dL
Magnesium	1.6	1.5	1.6-2.6 mEq/L
Protein, total	6.9	7.1	5.5-9 g/dL
Albumin	4.4	4.3	3.5-5.5 g/dL
Aminotransferase,aspartate (AST)	24	21	10-40 units/L
Aminotransferase,alanine (ALT)	26	24	10-40 units/L
Lactic dehydrogenase (LDH)	103	99	80-225 units/L
Alkaline phosphatase	52	55	30-120 units/L
Bilirubin, Total	0.5	0.4	0.3-1 mg/dL
Leukocytes (WBC)	5.6	5.9	4.5-11 x10³/mcL
Red blood cells (RBC), Female	4.8	4.8	4.3-5.7 x10⁸/mcL
Hemoglobin, Female	14.7	14.9	12-16 g/dL
Hematocrit, Female	40.6	42	37-47 %
Mean corpuscular hemoglobin (MCH)	31	33	27-33 picogram
Mean corpuscular volume (MCV)	83	87	76-100 mcm³
Platelets	214	225	150-450 x10³/mcL
International normalized ratio (INR)	1.0	1.1	0.8-1.2
Prothrombin time (PT)	10.4	10.6	9.5-11.3 sec
Partial thromboplastin time,activated (aPTT)	31	31	25-35 sec

Additional Labs:

Date	PEFR (L/min)	% predicted	FEV₁	% predicted	FVC	FEV₁/FVC ratio
Today	259	67	1.59	63	2.48	0.64
2 weeks ago	283	73
1 mo. ago	321	83
2 mo. ago (ED)	163	42

Cultures:

None

Imaging Studies:

X-ray (2 mo. ago)

Clear in all fields, some flattening of the diaphragm.

Vital Sign	10/19/25 09:18	08/20/25 08:37
Height (cm)	155	155
Weight (kg)	55	57
Body Temperature (°C)	37	37.2
Blood Pressure (mmHg)	138 / 88	132/92
Heart Rate (bpm)	94	88
Respiratory Rate (bpm)	19	20
Oxygen Saturation (%)	91	94

Current Orders

Medication
History

Singulair 10mg, 1 tablet by mouth daily, used for 1 year, stopped at ED visit (2 mo. ago) and Flovent started
Allegra D, 1 tablet by mouth daily, used for 1 month, changed to cetirizine (5 mo. ago) due to concerns over blood pressure

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

Patient Name: LeBlanc, Remi Date of Birth: 2/17/2001 Room#: Exam #1	Allergies:	Immunization History:
Community Rx Info: Rx Insurance:	Social History:
Additional Notes:

DRUG STRENGTH DF	STRENGTH ROUTE FREQ	PRN?	LAST DOSE (date/time)	ADVERSE EFFECTS	ADHERENCE	NOTES	MED REC ACTION
Fluticasone 44 mcg/puff HFA Inhaler	1 puff PO BID	no	22:00 10/18/25	none	never misses	has taken regularly since ED visit
Albuterol Sulfate 108 mcg/puff HFA inhaler	2 puffs PO q4-6H	yes, SOB	17:00 10/18/25	none	see note	Has always used at least once daily. Has been using 1-2 times a day since her emergency department visit. An inhaler lasts about 45 days.
Famotidine 20 mg tablet	1 PO QD	no	9:00 10/18/25	none	misses 1-2x/month
Lisinopril 20 mg tablet	1 PO QD	no	9:00 10/18/25	none	misses 1-2x/month
Yaz 3 mg/0.02 mg tablet	1 PO QD	no	9:00 10/18/25	none	never misses
Cetirizine 10 mg tablet	1 PO QD	yes, rhinorrhea		none	only takes when her nose gets runny
							Action Key: C = Continue, D = Discontinue^, H = Hold^, M = Modify^* ^*must provide reason

Medication

10/19/25

Clinical Notes

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: LeBlanc, Remi

Date of Birth: 2/17/2001

Room: Exam #1

Medication (name/strength)	Dose	Route	Frequency	Notes

Height	155 cm
Actual Body Weight (ABW)	55 kg
Ideal Body Weight (IBW)	47.8 kg
ABW % of IBW	115 %
Adjusted Body Weight (AjBW)	50.7 kg
Body Surface Area (BSA)	1.54 m²
Body Mass Index (BMI)	22.9 kg/m²