Ms. E is a pleasant, 15-year-old, white, female.
Source: Self, reliable source
Chief complaint: “I have acne.”
HPI: Patient states she has had inflamed bumps on her face for the past year or two. She has tried over-the-counter benzoyl peroxide 5%, which doesn’t help too much. She has been using it for the past 4 months, every night. She has not tried any other medications.
Benzoyl peroxide, 5%, applied nightly
Ortho-Cyclen: Ethinyl estradiol 0.035 mg and norgestimate 0.25 mg, 21 days of active tabs and 7 days of placebo
Pertinent History: None
Health Maintenance. Immunizations: Immunizations up to date
Family History: No cancer, cardiac, pulmonary or autoimmune disease in immediate family members
Social History: Patient lives with her older brother, mom and dad. She denies any use of nicotine, alcohol or drugs
ROS: Incorporated into HPI
VS – BP: 118/68, HR: 86, RR: 16, Temp 97.6, oxygenation 100%, weight: 140 lbs, height: 64 inches.
Ms. E is alert, awake, oriented x 3. Patient is clean and dressed appropriate for age
Cardiac: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
Respiratory: Clear to auscultation
Integumentary: Moderate inflammatory papules and pustules. Some erythema is present and mild scarring
Diagnosis: Moderate acne ICD-10: L70.9
Please answer the following: