Established patient to Dermatology, presents for reevaluation of acne

Patient Information

• Name: [Patient's Name]
• Date of Birth: [Patient's DOB]
• Sex: Female
• Medical Record Number: [MRN]

Chief Complaint

Acne reevaluation and rash on chest, stomach, neck, and back

History of Present Illness

49-year-old white female, established patient to Dermatology, presents for reevaluation of acne. She reports a rash on her chest, stomach, neck, and back for the past two months. Examination reveals flaring of acne with small folliculitis lesions. Patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1 but has been out of medication for three days. She also inquiries about cosmetic procedures and skin care products.

Family, Social, and Allergy History

• Family history includes hay fever, eczema, sinus issues, and hives.
• No history of melanoma, skin cancers, or psoriasis in the family.
• Mother had oral cancer.
• Patient is a nonsmoker.
• No blood tests conducted.
• History of sunburn in the past.
• Current medications include Lexapro, Effexor, Ditropan, aspirin, and vitamins.
• On benzoyl peroxide and Daypro.

Physical Examination

• Well-developed, appears stated age.
• Overall good health.
• Acne lesions on face and neck.
• Small folliculitis-like lesions on abdomen, chest, and back.

Assessment and Plan

• Assessment:

1. Acne with folliculitis.
2. Flaring of acne with small folliculitis lesions.
3. Out of medication for three days.

• Plan:

1. Continue amoxicillin 500 mg two at bedtime for acne and folliculitis.
2. Add Septra DS every morning with extra water for additional coverage of folliculitis.
3. Continue Tazorac cream 0.1 on face, back, and chest for acne management.
4. Refer to ABC clinic for an aesthetic consult to address patient's cosmetic concerns.
5. Follow-up in two months for reevaluation of acne and folliculitis.