![Chart Notes (Patient: [REDACTED], Case #HM-2021-04872)](https://anchor.is/_next/image?url=https%3A%2F%2Fvncl-anchor-images.s3.us-east-2.amazonaws.com%2Fon-demand%2F1778659556_upscale.png&w=3840&q=75)
[REDACTED] COMMUNITY HEALTH CENTER ELECTRONIC HEALTH RECORD — CONSOLIDATED CHART
Patient: [REDACTED], [REDACTED] A. DOB: [REDACTED] (Age 32 at initial visit) MRN: [REDACTED] Insurance: Medicaid PCP: [REDACTED], MD
Linked household members (same PCP): — [REDACTED], [REDACTED] J. (son, age 7 at initial visit, MRN [REDACTED]) — [REDACTED], [REDACTED] M. (mother, age 67 at initial visit, MRN [REDACTED])
10/14/2021 — OFFICE VISIT (ADULT)
CC: "Cough won't go away."
S: 32 y/o female, 3-week persistent dry cough, nasal congestion, bilateral eye irritation. Onset following flooding of primary residence 09/17/2021. Reports visible mold on interior walls and ceiling. No prior hx asthma or allergies. Non-smoker. Lives with son (7) and mother (67, hx COPD, DM2). Home sustained ~26 in. floodwater. Drywall removed to 4 ft. Patient states she has applied for FEMA HMGP buyout through county.
O: BP 122/78, HR 82, RR 16, SpO2 98%, Wt 148. Nasal mucosa erythematous, edematous. Lungs CTA bilat.
A:
- Allergic rhinitis, unspecified (J30.9)
- Mold exposure, residential (Z77.120)
P:
- Cetirizine 10mg daily
- Fluticasone nasal spray 50mcg, 2 sprays each nostril daily
- Mold remediation discussed. Patient states cost exceeds resources; awaiting buyout determination.
- RTC 6 weeks or sooner if worsening.
11/03/2021 — EXTERNAL CORRESPONDENCE (Scanned to chart)
[REDACTED] County Office of Emergency Management
Dear Property Owner,
This confirms receipt of your pre-application for the FEMA Hazard Mitigation Grant Program (HMGP), submitted in connection with Presidential Disaster Declaration DR-[REDACTED]. Your property has been identified as a potential candidate for voluntary acquisition.
The HMGP application process involves multiple phases, including environmental review, benefit-cost analysis, and property appraisal. Each phase may require 3 to 18 months.
No action is required at this time.
01/11/2022 — OFFICE VISIT (PEDIATRIC)
CC: "Coughing at night. Almost every night."
S: 7 y/o male, no prior asthma dx. 6-week hx nighttime cough, intermittent wheezing with exertion. Sleeps in bedroom where mold visible on wall behind dresser. Mother cleaned with bleach. Mold returned within 2 weeks.
O: HR 92, RR 20, SpO2 98%. Scattered expiratory wheezes bilat. No retractions.
A:
- Mild intermittent asthma (J45.20)
- Mold exposure, residential (Z77.120)
P:
- Albuterol HFA 90mcg, 2 puffs PRN, spacer provided
- Trigger avoidance counseled. Mother states family unable to relocate.
- Asthma action plan provided.
- RTC 3 months or if rescue inhaler use >2 days/week.
03/28/2022 — EXTERNAL CORRESPONDENCE (Scanned to chart)
[REDACTED] State Division of Emergency Management
To proceed with review of your property for acquisition under the HMGP, the following documentation is required within 60 days:
— Proof of property ownership (deed or title) — Flood insurance declaration page or documentation of non-participation — Copies of all FEMA Individual Assistance and/or SBA loan documentation — Completed Voluntary Participation Agreement (enclosed)
Failure to submit required documentation within the stated timeframe may result in removal from the applicant pool.
06/22/2022 — OFFICE VISIT (ADULT)
CC: "I can't sleep."
S: 32 y/o female, f/u rhinitis. Nasal symptoms persistent. New: difficulty falling asleep (onset ~3 months), waking 2-3x nightly. Reports checking weather and river gauge app "all the time." Irritability, difficulty concentrating at work. Denies SI/HI.
O: BP 134/82, HR 88, SpO2 97%, Wt 144. Affect anxious. Tearful when discussing housing.
A:
- Adjustment disorder with anxiety (F43.22)
- Insomnia, unspecified (G47.00)
- Allergic rhinitis, persistent (J30.9)
P:
- Hydroxyzine 25mg QHS PRN
- Sleep hygiene counseled
- Continue fluticasone nasal
- Behavioral health referral. Waitlist: 12 weeks.
09/15/2022 — OFFICE VISIT (PEDIATRIC)
CC: "The inhaler isn't enough."
S: 8 y/o male, f/u asthma. Nighttime cough 3-4x/week. Rescue inhaler 3-4 days/week. One missed school week last month. Mold exposure unchanged.
O: HR 88, RR 20, SpO2 97%. Expiratory wheezes bilat.
A:
- Mild persistent asthma (J45.30), reclassified
- Mold exposure, ongoing (Z77.120)
P:
- Start fluticasone HFA 44mcg, 2 puffs BID (Step 2)
- Continue albuterol PRN
- School nurse notified. Updated action plan.
- Mother states buyout pending. No timeline provided by county.
11/09/2022 — EXTERNAL CORRESPONDENCE (Scanned to chart)
FEMA Region [REDACTED]
The EHP review for the above-referenced project has been initiated. Estimated timeline: 6-12 months.
Application status: Under Review.
01/18/2023 — OFFICE VISIT (ELDER)
Patient: [REDACTED], [REDACTED] M. Age: 68.
CC: "Can't catch my breath in the house."
S: 68 y/o female, hx COPD (GOLD Stage II), DM2, HTN. Presenting with 3-week worsening dyspnea, productive cough with yellow-green sputum. Symptoms worse indoors. Using supplemental O2 1-2L intermittently at home. Daughter reports visible mold in patient's bedroom and bathroom. Patient sleeps in recliner in living room due to bedroom mold. DM2 management complicated by irregular meal schedule and difficulty affording test strips. A1C last check 8.4%.
O: BP 152/88, HR 98, RR 24, SpO2 92% RA, 95% on 2L NC. Wt 186. Rhonchi bilat, diminished breath sounds at bases. Bilateral pedal edema 1+.
A:
- Acute exacerbation of COPD (J44.1)
- COPD, moderate (J44.1)
- DM2, uncontrolled (E11.65)
- Mold exposure, residential (Z77.120)
- Inadequate housing (Z59.1)
P:
- Prednisone 40mg x5 days
- Azithromycin 250mg x5 days
- Increase home O2 to 2L continuous
- Adjust metformin to 1000mg BID
- Diabetic educator referral
- Daughter states family awaiting FEMA buyout. Unable to remediate. Unable to relocate.
- RTC 2 weeks. If worsening, ER.
02/08/2023 — OFFICE VISIT (ADULT)
CC: "I need something stronger."
S: 33 y/o female. Hydroxyzine insufficient. Sleep 3-4 hrs/night. Persistent worry re: housing, finances, son's health. Three homes on block now vacant. Two through buyout, one abandoned. Reports feeling unsafe at night. Mother (68) recently treated for COPD exacerbation, now on 2L O2 continuous.
O: BP 138/86, HR 94, Wt 138. PHQ-9: 14. GAD-7: 16. Affect flat.
A:
- Generalized anxiety disorder (F41.1)
- Insomnia disorder (F51.01)
- Chronic rhinosinusitis (J32.9)
P:
- Start sertraline 50mg daily
- Trazodone 50mg QHS
- D/C hydroxyzine
- Behavioral health referral, expedited. Waitlist: 16 weeks.
- Social work referral.
04/12/2023 — CASE MANAGEMENT NOTE
Author: [REDACTED], LCSW
Three of seven homes on block vacant. Streetlight out 5+ months; city unresponsive. Mother fell on damaged front steps last week. Patient states FEMA buyout pending 18 months. No appraisal scheduled. Contacted county; told environmental review "still in progress."
Patient states: "They told me not to make any repairs because the house is going to be torn down. So we just live in it like this."
Discussed Section 8 waitlist: 18-24 months. Does not meet criteria for emergency housing.
08/02/2023 — EXTERNAL CORRESPONDENCE (Scanned to chart)
[REDACTED] County Office of Emergency Management
The property appraisal previously scheduled for July 2023 has been postponed pending completion of the EHP review. You will be notified when the appraisal is rescheduled.
Application status: Under Review.
09/27/2023 — OFFICE VISIT (PEDIATRIC)
CC: "His teacher says he can't focus."
S: 9 y/o male. Daily rescue inhaler use. Nighttime awakenings 4-5x/week. Two courses oral prednisone in 6 months. School reports reading 1.2 years below grade level, difficulty sustaining attention, frequent nurse visits. Patient states: "I don't like my house. It smells bad."
O: HR 96, RR 22, SpO2 96%. Diffuse expiratory wheezes, prolonged expiratory phase.
A:
- Moderate persistent asthma (J45.40), reclassified
- Mold exposure, ongoing (Z77.120)
- Inadequate housing (Z59.1)
P:
- Step-up: budesonide/formoterol 80/4.5mcg, 2 puffs BID + PRN (SMART protocol)
- Add montelukast 5mg daily
- Referral pediatric pulmonology. Est. wait: 8 weeks.
- School accommodation letter. Request 504 evaluation.
- Mother states: "I know. We can't leave."
04/18/2024 — ADMINISTRATIVE NOTE
Patient [REDACTED], A. did not present for scheduled follow-up. Unable to reach by phone.
04/18/2024 — ADMINISTRATIVE NOTE (PEDIATRIC)
Patient [REDACTED], J. did not present. Same household.
05/03/2024 — EMERGENCY DEPARTMENT NOTE (PEDIATRIC)
Patient: [REDACTED], J. Age: 10. Arrival: 02:14 via personal vehicle.
CC: Acute respiratory distress.
S: Mother reports child woke ~01:30 with severe dyspnea, unable to speak in full sentences. Rescue inhaler x3 without relief. Home flooded second time 04/12/2024 (~14 in.). Family evacuated 3 days, stayed with relatives 3 weeks, returned 05/01. "Nowhere else to stay." Visible mold throughout home.
O: HR 132, RR 34, SpO2 91% RA. Intercostal retractions. Diffuse wheezing. Diminished air entry at bases.
Course: Continuous neb albuterol x3. IV methylprednisolone 1mg/kg. SpO2 improved to 95% on 2L NC. Admitted observation.
Discharge 05/04/2024: Prednisone burst x5 days. Continue maintenance regimen. PCP f/u 2-3 days. Home environment assessment strongly recommended. Second flood event in 32 months. FEMA buyout pending since 2021.
06/07/2024 — EXTERNAL CORRESPONDENCE (Scanned to chart)
[REDACTED] State Division of Emergency Management
Our office has been notified of additional flood damage to your property. Please submit within 90 days:
— Documentation of any Individual Assistance received for the 04/2024 event — Flood insurance claims documentation — Updated property photographs
A duplicate benefits review is required before your application can proceed.
Application status: Under Review — Administrative Hold.
08/14/2024 — OFFICE VISIT (ADULT)
CC: "We're back in the house."
S: 34 y/o female. Returned to home after 6 weeks with relatives. Cough worsened. Sleep 2-3 hrs/night. Mother (69) hospitalized 07/2024 COPD exacerbation, now home on 2L O2 continuously. Son hospitalized May. One remaining occupied house on block.
O: BP 142/90, HR 96, SpO2 96%, Wt 134. PHQ-9: 18. GAD-7: 18. Lungs: rhonchi bilat.
A:
- GAD, uncontrolled (F41.1)
- Insomnia disorder (F51.01)
- Chronic rhinosinusitis (J32.9)
- Hypertension, stage 1 (I10) — new
- Unintentional weight loss (R63.4)
P:
- Increase sertraline to 100mg
- Trazodone to 100mg QHS
- Start lisinopril 10mg daily
- Pulmonology referral
- Patient states: "They told me not to fix the house. They told me not to sell the house. They told me to wait."
11/20/2024 — EXTERNAL CORRESPONDENCE (Scanned to chart)
[REDACTED] County Office of Emergency Management
Due to the passage of time since initial application, an updated benefit-cost analysis is required. The previous BCA, completed 2022, has exceeded its period of validity.
No action is required at this time.
02/19/2025 — PEDIATRIC PULMONOLOGY CONSULTATION
Patient: [REDACTED], J. Age: 10.
Referral: Moderate persistent asthma, poor control despite Step 4 therapy. 4 ER visits in 12 months. Ongoing mold exposure.
Spirometry: FEV1 68% predicted. FEV1/FVC 0.72. Moderate obstruction. Positive bronchodilator response (14%).
Assessment: Severe persistent asthma (J45.50), reclassified. Chronic mold exposure is primary identifiable trigger. Trajectory consistent with literature on sustained damp-housing exposure in pediatric populations: persistent allergen sensitization, airway remodeling.
Plan:
- High-dose ICS/LABA: fluticasone/salmeterol 250/50, 1 puff BID
- Continue montelukast
- Discuss biologic therapy if no improvement 8 weeks
- Repeat spirometry 3 months
- Environmental modification remains critical. Per caregiver, family resides in flood-damaged home with documented mold. FEMA buyout pending since September 2021.
05/07/2025 — CASE MANAGEMENT NOTE
Author: [REDACTED], LCSW
Son transferred schools twice this academic year. 14 absences this semester. School psychologist evaluation: attention problems, anxiety symptoms. Mother reports son has not had a friend to the home in over a year. Patient's mother hospitalized again 03/2025 (COPD exacerbation, 4-day admission). Patient is sole caregiver for son and mother. Two occupied homes remain on block. Mail delivery irregular. Water main break on street in February, not repaired for 11 days.
Buyout status unchanged. County submitted updated BCA to state in March.
Patient: "I stopped thinking they were going to help us. I just need them to let us go."
09/10/2025 — EXTERNAL CORRESPONDENCE (Scanned to chart)
[REDACTED] County Office of Emergency Management
The appraisal for your property has been completed. Pre-event fair market value: $[REDACTED]. Please allow 60-90 days for review and processing of purchase offer.
01/14/2026 — OFFICE VISIT (ADULT)
S: 35 y/o female. No purchase offer received. Contacted county in December; told "still processing." Son: 4 ER visits past 12 months. Mother homebound, continuous O2. Insomnia unchanged. Chest tightness, daily headaches. Reports she has stopped checking the mail.
O: BP 148/94, HR 92, SpO2 96%, Wt 132. PHQ-9: 19. GAD-7: 17.
A:
- Hypertension, uncontrolled (I10)
- GAD, uncontrolled (F41.1)
- Insomnia disorder (F51.01)
- Weight loss, 16 lbs from baseline (R63.4)
P:
- Increase lisinopril to 20mg
- Trazodone to 150mg QHS
- Continue sertraline 100mg
- Pulmonology f/u pending. Wait: 10 weeks.
- Continue to monitor.
03/04/2026 — EXTERNAL CORRESPONDENCE (Scanned to chart)
[REDACTED] State Division of Emergency Management
Due to updated federal guidelines for Environmental and Historic Preservation compliance, additional review is required before a purchase offer can be extended. Please submit the following within 60 days:
— Updated proof of property ownership — Updated flood insurance documentation — Signed acknowledgment of deed restriction requirements (enclosed)
Application status: Under Review.
04/22/2026 — OFFICE VISIT (PEDIATRIC)
Patient: [REDACTED], J. Age: 11.
CC: Refill.
S: Asthma "about the same." Daily rescue inhaler. 14 absences this semester. School psychologist: attention problems, anxiety. Difficulty sleeping. Asks frequently when they are moving. Has not had a friend to the home in over a year. Mother reports buyout application returned to review status.
O: HR 88, RR 20, SpO2 95% RA. Diffuse wheezing. Wt 25th percentile (was 50th at age 7). Affect guarded. Minimal eye contact.
PSC-17: Elevated internalizing and attention subscales.
A:
- Severe persistent asthma (J45.50)
- Mold exposure, residential, ongoing (Z77.120)
- Inadequate housing (Z59.1)
- Adjustment disorder with anxiety (F43.22)
- Attention problems, evaluate further
P:
- Continue current asthma regimen. Pulmonology f/u 06/2026.
- Referral developmental-behavioral pediatrics. Est. wait: 4-6 months.
- Referral pediatric behavioral health. Waitlist: 14 weeks.
- School accommodation letter updated.
- Mother states: "They sent the same letter they sent in 2022."
Things to follow up on...
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The five-year buyout clock: NRDC's first-ever nationwide analysis of more than 43,000 FEMA-funded property acquisitions found that the typical buyout takes over five years from flood to closeout, with lower-income households disproportionately likely to drop out or return to damaged homes while waiting.
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Kinston's erased neighborhood: In one of FEMA's earliest large-scale buyout programs, 95% of property owners in Kinston, North Carolina's historically Black Lincoln City neighborhood accepted offers, but researchers documented that many felt they had no practical choice and some relocated families subsequently entered foreclosure.
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Mold persists for years: A study of Hurricane Harvey survivors found that 82% of participants' homes showed mold within 45 days of flooding, and 66.7% still had visible mold 12 to 14 months later, with widespread financial barriers to remediation driving long-term exposure.
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Children and damp housing: A 2024 state-of-the-science review in Environmental Health Perspectives found significant associations between damp housing exposure and emotional dysregulation in children under 10, with effect measures ranging to 40% increases in odds of symptoms.