15 Yo

Ms. E is a pleasant, 15-year-old, white, female.

Source: Self, reliable source

Subjective:

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. 

Allergies: NKA

Current Mediations:

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

Objective:

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

Assessment:

Diagnosis: Moderate acne ICD-10: L70.9

Please answer the following:

1. Using the guidelines of the American Academy of Dermatology reviewed in this week’s lecture, what is your treatment plan (include specific dosage and frequency)? Why did you choose this treatment plan?  In your answer, please describe, briefly, the pharmacodynamics (1 point) and pharmacokinetics (1 point) of your treatment choice and how they influenced your choice. Does the patient have any comorbidities that influenced your choice as well (1 point)?  Are there any medical interactions to your choice (1 point)? 


2. Document the education you would provide for this patient, specific to the prescribed medication(s). Please include information pertinent to the patient (2 points) and common potential adverse effects (2 points).