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1、NoteforJaneDoeon4/8/03-Chart2646ChiefComplaint(1/1):This19yearoldfemalepresentstodaycomplainingofacnefromcontinuallywashingarea,frequentphoneusesothereceiverrubsonfaceandoralcontraceptiveuse.Location:Sheindicatestheproblemlocationisthechin,righttempleandleftt
2、emplelocally.Severity:Severityofconditionisworsening.Menses:Onset:13yearsold.Interval:22-27days.Duration:4-6days.Flow:light.Complications:none.Allergies:Patientadmitsallergiestopenicillinresultingindifficultybreathing.MedicationHistory:Patientiscurrentlytakin
3、gAlesse-28,20mcg-0.10mgtabletusagestartedon08/07/2001medicationwasprescribedbyObstetrician-GynecologistA.PastMedicalHistory:FemaleReproductiveHx:(+)birthcontrolpilluse,ChildhoodIllnesses:(+)chickenpox,(+)measles.PastSurgicalHistory:Noprevioussurgeries.FamilyH
4、istory:Patientadmitsafamilyhistoryofanxiety,stressdisorderassociatedwithmother.SocialHistory:PatientadmitscaffeineuseSheconsumes3-5servingsperday,PatientadmitsalcoholuseDrinkingisdescribedassocial,Patientadmitsgooddiethabits,Patientadmitsexercisingregularly,P
5、atientdeniesSTDhistory.ReviewofSystems:Integumentary:(+)periodicreddeningofface,(+)acneproblems,Allergic/Immunologic:(-)allergicorimmunologicsymptoms,ConstitutionalSymptoms:(-)constitutionalsymptomssuchasfever,headache,nausea,dizziness.PhysicalExam:Patientisa
6、19yearoldfemalewhoappearspleasant,innoapparentdistress,hergivenage,welldeveloped,wellnourishedandwithgoodattentiontohygieneandbodyhabitus.Skin:Examinationofscalpshowsnoabnormalities.Hairgrowthanddistributionisnormal.Inspectionofskinoutsideofaffectedareareveal
7、snoabnormalities.Palpationofskinshowsnoabnormalities.Inspectionofeccrineandapocrineglandsshowsnoevidenceofhyperidrosis,chromidrosisorbromhidrosis.Faceshowskeratoticpapule.Impression:Acnevulgaris.Plan:Recommendedtreatmentisantibiotictherapy.Janereceivedextensi
8、vecounselingaboutacne.Sheunderstandsacnetreatmentisusuallylong-term.Returntoclinicin4week(s).PatientInstructions:Patientreceivedliteratureregardingacnevulgaris.Discussedwiththepatientthep
