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Audrea is a 20-year-old female with chronic sinusitis and a history of risk activity involvement, currently on inhaled and antihistamine therapy plus an epinephrine auto-injector for possible allergy/asthma management. She recently had an encounter for viral sinusitis and has been followed prenatally, with one visit noting a congenital uterine anomaly amid otherwise normal pregnancy visits.
Drives care
- Chronic sinusitis
- Risk activity involvement
- Congenital uterine anomaly noted during pregnancy
- Possible asthma/allergy requiring inhalers and epinephrine auto-injector
Watch
- No recent lab/imaging abnormal results on file - confirm testing status
- Clarify indication and allergy history behind epinephrine auto-injector prescription
- Ensure follow-up for congenital uterine anomaly in context of pregnancy care
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5 × Reproductive health · 2 × Mental health.
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Active problems
| Condition | Status | Onset |
|---|---|---|
| Chronic sinusitis (disorder) | active | Apr 25, 2023 |
| Risk activity involvement (finding) | active | Sep 1, 2021 |
Active medications
| Medication | Dosage | Since |
|---|---|---|
| albuterol 0.83 MG/ML Inhalation Solution | Take as needed. | Sep 23, 2025 |
| budesonide 0.25 MG/ML Inhalation Suspension | Take as needed. | Sep 23, 2025 |
| NDA020800 0.3 ML Epinephrine 1 MG/ML Auto-Injector | Take as needed. | Nov 14, 2009 |
| Fexofenadine hydrochloride 30 MG Oral Tablet | Take as needed. | Nov 9, 2009 |
Allergies
| Substance | Reaction | Verification |
|---|---|---|
| Allergic disposition (finding) | — | confirmed |
| Mold (organism) | — | confirmed |
| House dust mite (organism) | — | confirmed |
| Animal dander (substance) | Eruption of skin (disorder) | confirmed |
| Grass pollen (substance) | — | confirmed |
| Tree pollen (substance) | — | confirmed |
Recent results
| Test | Value | When |
|---|---|---|
| Hemoglobin | 13.944 g/dL | Sep 23, 2025 |
| WBC | 5.949 10*3/uL | Sep 23, 2025 |
| Respiratory rate | 15 /min | Sep 23, 2025 |
| Heart rate | 83 /min | Sep 23, 2025 |
| BMI | 23.62 kg/m2 | Sep 23, 2025 |
| Body weight | 62.8 kg | Sep 23, 2025 |
| Pain severity | 2 {score} | Sep 23, 2025 |
| Body height | 163 cm | Sep 23, 2025 |
| Respiratory rate | 14 /min | Sep 17, 2024 |
| Heart rate | 68 /min | Sep 17, 2024 |
| BMI | 22.94 kg/m2 | Sep 17, 2024 |
| Body weight | 60.9 kg | Sep 17, 2024 |
| Pain severity | 1 {score} | Sep 17, 2024 |
| Body height | 163 cm | Sep 17, 2024 |
| Respiratory rate | 14 /min | Sep 12, 2023 |
| Heart rate | 60 /min | Sep 12, 2023 |
| BMI | 22.22 kg/m2 | Sep 12, 2023 |
| Body weight | 59 kg | Sep 12, 2023 |
| Pain severity | 2 {score} | Sep 12, 2023 |
| Body height | 163 cm | Sep 12, 2023 |
| Respiratory rate | 15 /min | May 3, 2023 |
| Heart rate | 71 /min | May 3, 2023 |
| BMI | 21.86 kg/m2 | May 3, 2023 |
| Body weight | 58 kg | May 3, 2023 |
| Pain severity | 3 {score} | May 3, 2023 |
| Body height | 162.9 cm | May 3, 2023 |
| Hemoglobin | 16.878 g/dL | Aug 25, 2020 |
| WBC | 7.879 10*3/uL | Aug 25, 2020 |
Notes & documents
| Document | Author | Date | |
|---|---|---|---|
| No unrestricted documents. | |||
Claims
| Claim | Payer | Date | Status | Billed | Paid | |
|---|---|---|---|---|---|---|
| CLM-2026078002 | Medicaid | Sep 24, 2025 | paid | $1,186.78 | $1,994.67 | Lines |
| CLM-2026078001 | Medicaid | Sep 24, 2025 | denied | $129.94 | $0.00 | Lines |
| CLM-2026078000 | Medicaid | Sep 24, 2025 | paid | $129.94 | $0.00 | Lines |
| CLM-2026078003 | Medicaid | Sep 10, 2025 | paid | $85.55 | $0.00 | Lines |
| CLM-2026078004 | Medicaid | Jan 28, 2025 | paid | $1,005.38 | $690.24 | Lines |
| CLM-2026078005 | Medicaid | Jan 8, 2025 | paid | $142.58 | $99.81 | Lines |
| CLM-2026078006 | Medicaid | Dec 11, 2024 | paid | $14,114.78 | $11,177.76 | Lines |
| CLM-2026078007 | Medicaid | Nov 13, 2024 | paid | $42,069.87 | $33,541.83 | Lines |
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