Chapter4 Chartnote1 JessicaGilliand
Jennifer Summers
October 28, 2014
Patient is seen in follow up today for her acne. On her last visit in August she was found to have multiple inflammatory papules, and pustules with some deep cyst on the face, neck, and back. There was some scaring on both cheeks. Various topical treatments and systemic antibiotics have not been successful in controlling this ________ acne. After counseling with the patient and her mother last visit it was agreed we would start her on Accutane. Exam today shows remarkable improvements. There are some residual lesions without any new inflammatory cysts or pustules. A few comedones are present on the nose. She states she has been using the Accutane as directed and is taking her contraceptive pills faithfully.
DIAGNOSIS
Inflammatory acne vulgaris on Accutane. She and her mother were again counseled about the high risk of birth defects should she become pregnant while taking Accutane. She denies being sexually active but her mother was present in the room. She is to follow up in the office in one month.
_____________________________
James Wood, MD
JW:JG
10/28/2014
10/28/2014
October 28, 2014
Patient is seen in follow up today for her acne. On her last visit in August she was found to have multiple inflammatory papules, and pustules with some deep cyst on the face, neck, and back. There was some scaring on both cheeks. Various topical treatments and systemic antibiotics have not been successful in controlling this ________ acne. After counseling with the patient and her mother last visit it was agreed we would start her on Accutane. Exam today shows remarkable improvements. There are some residual lesions without any new inflammatory cysts or pustules. A few comedones are present on the nose. She states she has been using the Accutane as directed and is taking her contraceptive pills faithfully.
DIAGNOSIS
Inflammatory acne vulgaris on Accutane. She and her mother were again counseled about the high risk of birth defects should she become pregnant while taking Accutane. She denies being sexually active but her mother was present in the room. She is to follow up in the office in one month.
_____________________________
James Wood, MD
JW:JG
10/28/2014
10/28/2014