RxPert
Sova Orr, a 21-year-old male with a lean build, strides into the pharmacy. He's neatly dressed in a casual hoodie and jeans, a clear contrast to the nervous expression on his face. Tucked under his arm is a piece of paper from his primary care provider, detailing a new diagnosis of asthma and a referral for a pharmacy consultation about asthma management. Despite his athletic appearance, Sova pauses frequently to catch his breath, a sign of his recent respiratory troubles. He approaches the pharmacy counter, glancing around before focusing on you.
"Hi, I was told to speak to a pharmacist about starting some new asthma medication... are you the intern who's going to help me with that?"
Patient Info
Evaluation
200
Patient Information
Sova Orr
Age: 21
Date of Birth: 09/15/03
Gender: Male
Chief Complaint
Medical Conditions
Social History
occupation: Full-time college student
Living Situation: Family lives 1 hour away
Smoking Status: Non-smoker
alcohol Intake: Drinks about 1 beer per week
diet: Relatively balanced meals including salads, grilled chicken, and broccoli
Dining Out Frequency: 1-2 times per week
exercise: Walks around campus at least 3-4 times a week
Family History
Mother: Eczema and Asthma
Medications
Hydrochlorothiazide: 25 mg by mouth daily
Lisinopril: 20 mg by mouth daily
Metformin: 1000 mg by mouth twice a day
Multivitamin: 1 tablet by mouth daily
Review Of Systems
vision: No vision changes
cardiovascular: No chest pain or palpitations
respiratory: Cough and shortness of breath
Vitals
Blood Pressure: 128/78
Heart Rate: 74
Respiratory Rate: 34
temperature: 36.6 C
height: 6’0”
weight: 96.5 kg
Labs
latest:
electrolytes:
Na: 141
K: 4.1
Cl: 102
CO2: 25
BUN: 19
SCr: 1.2
Glu: 196
Lipid Panel:
Total Cholesterol: 172
HDL: 58
LDL: 72
triglycerides: 166
a1c:
current: 8
Three Months Ago: 8.9
Diagnostic Tests
upcoming: Spirometry and PEF with reversibility test scheduled for next week
Extra Information
Last Visit: 3 months ago for diabetes management