Sample Name: Acne Vulgaris - H&P
Description: Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris
(Medical Transcription Sample Report)
CHIEF COMPLAINT (1/1): This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use. Location: She indicates the problem location is the chin, right temple and left temple locally. Severity: Severity of condition is worsening.
Menses: Onset: 13 years old. Interval: 22-27 days. Duration: 4-6 days. Flow: light. Complications: none.
ALLERGIES: Patient admits allergies to penicillin resulting in difficulty breathing.
MEDICATION HISTORY: Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.
PAST MEDICAL HISTORY: Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.
FAMILY HISTORY: Patient admits a family history of anxiety, stress disorder associated with mother.
SOCIAL HISTORY: Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.
REVIEW OF SYSTEMS: Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /
Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms
such as fever, headache, nausea, dizziness.
IMPRESSION: Acne vulgaris.
PLAN: Recommended treatment is antibiotic therapy. Patient received extensive counseling about acne. She understands acne treatment is usually long-term. Return to clinic in 4 week (s).
PATIENT INSTRUCTIONS: Patient received literature regarding acne vulgaris. Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.
PRESCRIPTIONS: Tetracycline Dosage: 250 mg capsule Sig: BID Dispense: 60 Refills: 0 Allow Generic: Yes
Keywords: dermatology, acne, acne vulgaris, keratotic papule, apocrine glands, eccrine, hair growth, hyperidrosis, chromidrosis, bromhidrosis, tetracycline, vulgaris,