[doctor] kayla ward , date of birth , 4/28/07 . mrn 3-8-4-9-2-0 . she's here for a new visit with her mother for acne located on the face , which started about two years ago and is present most every day . she has been using persa-gel and washing regularly , which is somewhat helpful . there are no associated symptoms including itching , bleeding , or pain . no additional past medical history . she lives with her parents and sister . they have a dog , bird , and bunnies . she is in 7th grade . she plays basketball and volleyball and tap . she wears sunscreen in the summer , spf 30 . no additional family history . hi kayla , i'm dr. juan price . i hear you are starting to get some acne on the face . how about the chest and back ?
[patient] it's not too bad .
[doctor] so , it's not bad on the chest or back . you've used some over the counter items like washes and persa-gel ?
[patient] yeah .
[doctor] do those seem to be helping ?
[patient] yes , i think so , a little bit .
[doctor] good . what's your skin care routine like now ?
[patient] do you wan na know , like , the things i currently use ?
[doctor] yes . what do you do for your acne in the morning ? and then what do you do at nighttime ?
[patient] i wash my face , more like i wipe it down in the morning . then at night i use an elf facial cleanser called the super clarity cleanser . i finish with a toner and then the persa-gel .
[doctor] when you say , " wipe your face in the morning , " do you use a product or just water ?
[patient] mm , just water and a washcloth , really . if i feel really greasy , sometimes i'll use the elf cleanser in the morning , too .
[doctor] okay . and is today a good day , bad day , or an average day for you ?
[patient] mm , i would say it's probably a good day for me , of course , since i'm here , right ?
[doctor] acne is always good when you come to see the doctor . do you find that your acne flares with your periods ?
[patient] no , not really .
[doctor] and do you get a regular period ?
[patient] yup .
[doctor] how long have you been getting a regular period ?
[patient] mm , i think about two years .
[doctor] okay .
[patient_guest] the biggest flare , probably , was when she started school sports in the fall , just with all the sweating .
[doctor] yup , that will do it . is there anything else that you've noticed , mrs. ward ?
[patient_guest] no . kayla really has been doing a good job with the facial care regimen . it just does n't seem to help as much as we wanted .
[doctor] got it . okay . well , let's take a look then . full exam is performed today , except for under the underwear and under the bra . multiple benign nevi on the trunk and extremities . scattered skin colored papules . open and closed comedones . and erythmateous papules on the face , primarily on the forehead and with also some on the central cheeks and chin . the chest and back are relatively spared . and the remainder of the examination is normal . so , what i'm seeing from your exam today is mild to moderate acne , mostly comodonal with small inflammatory component .
[patient] okay , so is there anything we can do to help it ?
[doctor] yes . i would like to start with a topical therapy first . every morning , you will wash your face with a mild cleanser then use a moisturizer labeled , " noncomedogenic , " with sunscreen spf 30 or higher . this means it wo n't clog your pores . now , in the evening , wash your face with the same cleanser and allow it to dry . apply adapalene , 0.1 % cream , in a thin layer to the areas you generally get acne . i want you to start off using this a few nights a week and slowly work up to using it every night . if it is ... excuse me , if it is very expensive or not covered by insurance , you can try different gel over the counter . you can follow that with clean and clear persa-gel in a thin layer , or where you generally get acne . and then a noncomedogenic moisturizer . you're atopic retinoid will cause some sensitivity , so you will need to wear sunscreen when you are outside . it may also cause some dryness or irritation .
[patient] okay , i can do that .
[doctor] you also have multiple benign moles on your arms , legs , back and abdomen . this means they all look normal with no worrisome features . we will see if you have any progress over the next six months and follow up at that time .
[patient] okay , that sounds good . thank you .
[doctor] do you have any questions for me ?
[patient] no , i do n't think so .
[doctor] okay . if you have questions or concerns before your next visit , please call the office .
[patient] thank you , doctor , we will .
CHIEF COMPLAINT

New acne evaluation.

HISTORY OF PRESENT ILLNESS

Kayla Ward is a 15-year-old female who presents for new patient evaluation of acne located on the face. She is accompanied by her mother today.

Kayla states her acne started approximately 2 years ago and it is present almost every day. The patient’s mother notes that the most significant acne flares started in the fall when she was playing school sports. It does not tend to flare with her periods. Kayla reports that today is a good day for her acne. She denies any significant acne present on the chest or back. There are no associated symptoms, including no itching, bleeding, or pain.

The patient has been washing her face regularly. Her acne regimen includes washing her face in the morning with Persa-Gel and at night e.l.f. SuperClarify Cleanser along with toner and Persa-Gel. This regimen is somewhat helpful. She wears sunscreen in the summer SPF 30.

SOCIAL HISTORY

Lives with parents and sister. They have a dog, bird, and rabbits in the home. She is in the 7th grade and active in basketball, volleyball, and tap dancing.

FAMILY HISTORY

No significant family medical history.

PHYSICAL EXAM

Integumentary
Full exam is performed today except for under the underwear and under the bra. There are multiple benign nevi on the trunk and extremities. Scattered skin-colored papules, open and closed comedones, and erythematous papules on the face, primarily on the forehead, with also some on the central cheeks and chin. The chest and back are relatively spared. The remainder of examination is normal.

ASSESSMENT

• Comedonal acne.
• Multiple benign melanocytic nevi of upper and lower extremities and trunk.

Kayla Ward is a 15-year-old female seen today for new acne evaluation. Full skin examination revealed mild to moderate comedonal acne with a small inflammatory component and multiple benign melanocytic nevi of upper and lower extremities and trunk.

PLAN

Comedonal acne.
We discussed the diagnosis, etiology, and treatment options. I recommend starting with topical therapy first. The patient was instructed to wash face every morning with a mild cleanser, then use a non-comedogenic moisturizer with sunscreen SPF 30 of higher. In the evening, wash face with same mild cleanser and allow to dry. Apply a thin layer of topical retinoid, Retin-A 0.1% gel, to acne prone areas. Start off using a few nights a week, slowly work up to using every night. If it is very expensive or not covered by insurance, you can try Differin gel over the counter. Your topical retinoid will cause sun sensitivity, so you will need to wear sunscreen when you are outside. It may also cause some dryness or irritation.

Multiple benign melanocytic nevi of upper and lower extremities and trunk.
Reassurance given moles are normal in appearance and have no concerning characteristics. Will continue to monitor for progression or changes in 6 months.

INSTRUCTIONS

Follow recommended cleaning regimen.
Start Retin-A 0.1% topical gel, apply to acne prone areas, titrate as instructed.
Follow up in 6 months.
