CC: “I have a problem with acne.”
HPI: Meg is a 17 year old female who presents to the office with her mother. She is present for is a sports physical. The main sport she is active in is volleyball. Meg explains that her only medical problem is acne. She requests birth control pills to manage the acne problem. Meg’s mother minimizes the problem appropriately, but Meg expresses concern particularly because of an upcoming school dance.
The acne is mild and intermittent but distressing to Meg. It was explained that birth control pills are usually not the first line of treatment for acne. Meg explains that she has tried “those other pills” but they made her sick. She’d like to try birth control pills for the acne.
After the mother excuses herself from the examination room it is discussed with Meg whether she needed the birth control pills for birth control. Meg explains that she’s not sexually active. It’s reinforced that if she becomes sexually active that she should not count on the birth control pills to protect her from sexually transmitted diseases. Meg explains that she is educated on “STDs” and not to worry about this.
Past medical history: none
Medications: none
Allergies/Intolerances: “some pill given for acne” (presumably an antibiotic)
Family History:
Mother living
Father living
Siblings _________________________
No childrenTobacco: none
EtOH: none
Social History: Meg is a 17 year old high school student. She lives with both parents. Her activities involve helping in the care of her paternal grandmother and grandfather. Meg’s mother and Meg are providing the meals for the grandparents. Meg’s main social activities surround school friends and volleyball. She doesn’t participate in organized religion. She feels safe in her home and at school. Meg has a boyfriend. Meg has lived with her parents all of her life. She denies any usual stress between her and her family. She does express concern for her grandparents and mother when the summer is over because of the need for increased involvement in the care of the grandparents by her mother. Meg is not sexually active.
Review of systems:
General: No fever, chills, sweats, or night sweats.
HEENT: No headaches, visual or auditory change, nasal discharge or bleeding, sore throat, sore neck.
CV: No exert ional chest pain, PND, orthopnea, palpitations, syncope.
Pulm: No shortness of breath, wheezing, or cough.
GI: No nausea, vomiting, diarrhea, constipation, black or bloody stools.
GU: No urgency, frequency, or urethral discharge. Periods are usually regular at every 28 days.
Endo: No excess thirst, weight change, hot or cold intolerance.
Neuro: No history of seizures, strokes, TIA.
Heme: No bleeding or easy bruising.
Skin: See HPI above. She has concerns regarding acne. No other derm concerns noted.
Ms/Sk: No joint swelling or pain.
Psychiatric: No difficulties with excess anxiety, depression.Physical Examination:
T= 98.4
Pulse=82/min
Respirations = 20/min
BP = 108/66
Weight = 96 pounds
Height = 5 feet 6 inchesHEENT: normocephalic, PERRL, EOMI, Tympanic membranes normal, hearing normal, throat without errythema, nares patent, neck supple.
CV: HRRR. No murmur, rub, or click.
L: CTA
GI: Normal bowel sounds, non tender, no guarding rebound or rigidity.
GU: Normal vagina and cervix. Pap obtained. No adnexal tenderness or masses.
Rectal: Sphincter tone intact, stool brown and negative for occult blood.
Neurological: CN II to XII intake, Motor 5/5 and symmetrical, Sensation intact to soft touch vibration and temperature, Coordination intact to rapid alternating movements and heel to shin, Negative Rhomberg, Babinski not present bilaterally, Mental status normal.
Skin: a few scattered whiteheads on both sides of the face. No pitting or scaring present.Impressions:
- Acne
- Satisfactory health for participation in sports, specifically volleyball.
- Family stressors of multigenerational care issues.
Plan:
- Birth control pill trial. Follow up in three months. Discussion on sexual activity with mother in next room.
- Sports approval given patient.
- Offer to discuss and problem solve with patient and her mother given. Will discuss further at next appointment.
- Will draw CBC, glucose, renal and liver functions, and cholesterol.