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25 lines
1.2 KiB
Plaintext
25 lines
1.2 KiB
Plaintext
HOSPITAL
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Oakwood Community Clinic
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450 North Main Street
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Madison, WI 53703
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(608) 555-0102
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Patient Name: Isabella Garcia
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MRN: 9884021
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DOB: 11/05/1998
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Gender: Female
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Age: 26
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MRN: 9884021
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Accession: B11269-25
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Date: 06/20/2025
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The patient is a 26-year-old female with a history of persistent asthma since childhood. She reports seasonal exacerbations, typically in the spring and fall. Current medications include a daily inhaled corticosteroid and an albuterol inhaler for rescue use, which she reports using 3-4 times per week recently. She has a known allergy to dust mites and pollen. No history of smoking.
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PROCEDURES:
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Spirometry (pre- and post-bronchodilator): Demonstrated a reversible obstructive pattern, consistent with asthma. FEV1 increased by 15% after albuterol administration.
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Allergy Skin Testing: Positive reaction to tree pollen and dust mites.
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Chest X-ray (PA and Lateral): Lungs are clear. No acute infiltrate or edema.
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IMPRESSION:
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Moderate persistent asthma, sub-optimally controlled based on recent increase in rescue inhaler use.
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Allergic rhinitis.
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Patient Name: Johnathan Smith MRN: 8675309 Age: 67
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Electronically Signed By: Dr. David Chen, M.D.
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Date: 06/23/2025 Time: 08:56
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