Alejandra Gomez

Examine the image below to learn more about the client to write an appropriate and individualized prescription. 

Case: Alejandra Gomez, a 19-year-old female client (DOB: 10/31/2005), presents to the clinic complaining of frequent episodes of shortness of breath, cough, and chest tightness that have been getting worse over the past few years, especially during seasonal changes. The client states that her symptoms present occasionally, less than four days per week, and less than twice per month. The NP’s physical assessment reveals bilateral expiratory wheezes on auscultation with no retractions present. The rest of the physical exam is unremarkable. Since the history and physical support an asthma diagnosis, the NP orders pulmonary function tests that support an asthma diagnosis. After talking with Alejandra, the NP determined that she is motivated and capable of adhering to prescribed treatments. Based on current asthma CPGs, the NP decided to prescribe asthma medication for Alejandra and considered what would be appropriate. 

Past Medical History: None

Allergies: None

Medications: Multivitamin

Social History: She has never smoked cigarettes and does not drink alcohol. 

Physical Exam:

· Height:  5 feet 8 inches

· Weight: 125 lbs

· Body Mass Index (BMI): 19 

· Blood Pressure (BP): 110/71

· Heart Rate (HR): 85 

· Respiratory Rate (RR): 21  

· Oxygen Saturation (O2 Sat): 97% on RA 

· Temperature (TEMP): 98.6 oral