6531 Week 2 ihuman Facial Bumps
Patient Form
- Reason for visit – skin checkup bumps on face
- Known exposures within past 30 days – none
- Name of soap – squeaky clean body wash
- Name of moisturizer – none
- Name of shampoo – active wash for men
- Name of laundry detergent – clothes so clean
- Name of dryer sheets – dry fast
- Bathing regimen – shower 4 times per week
- Shaving regimen – safety razor (not electric shaver), uses soap primarily and shaving cream sporadically, tried father’s aftershave several times
- Current skin medications – none
- Family history of skin conditions – father with facial scarring (diagnosis unknown); several keloids (ear, arm, torso); no family history of skin cancer.
Subjective Data
Reason for encounter – bumps on face
History of Present illness – The patient is a 14-year old black male presenting with his older sibling with concerns of lesions on his face. Over the past four months, the patient has noticed an increased number of lesions on his face, particularly around his chin, jawline, nose, and cheeks. The patient describes the lesions and small raised bumps that occasionally become tender and then disappears within several days to weeks. The patient states the bumps got worse after recently starting shaving his face. He denies any itching or intense pain associated with lesions, but expresses frustration due to their appearance. He denies the use of any over-the –counter remedies.
Review of systems
General – denies fatigue, weight loss, fever, chills
HEENT/Neck – denies vision changes, hearing loss, tender or swollen lymph nodes
Cardiovascular – denies chest pain, palpitations, lower extremity swelling
Respiratory – denies shortness of breath, increase in cough or sputum production
Gastrointestinal – denies nausea, vomiting, diarrhea, constipation, reflex, melena, or hematochezia.
Genitourinary – denies increased urination or nocturia, reduced stream, dysuria, hematuria, frequency, or urgency.
Musculoskeletal- denies muscle pain, joint swelling
Neurologic- denies syncope, weakness, or lightheadedness
Psychiatric- denies anxious or depressed mood
Endocrine – denies heat or cold intolerance, denies excessive thirst, hunger, or urination
Hematologic/lymphatic – denies easy bleeding/bruising
Allergic/Immunologic – denies rashes or hives
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Past Medical History (PMH)
Birth history – 7lbs 2oz full-term infant born to 30-year old mother via normal spontaneous vaginal delivery. Uncomplicated birth.
Hospitalizations/surgeries – none
Medications – none
Allergies – None
Preventive Health – annual wellness exam; last 9 months ago. Biannual dental exams
Immunizations – influenza vaccine received for this season; COVID vaccinex2
Family History
- Mother – 44 yo, healthy
- Father – 46 yo, hypertension, unknown skin problems with pitting scars on face and chest
- Sibling – sister 17 yo, healthy
- Maternal grandmother – 67 yo, type II DM
- Maternal grandfather -69 yo, hypertension, hyperlipidemia
- Paternal grandmother – 71 yo, healthy
- Paternal grandfather – 72 yo, hypertension, stroke.
Social History
Tobacco – denies use
Alcohol –denies use
Drugs – denies use
Physical Exam
Vital Signs
Height – 64”
Weight – 133lb
BMI – 22.8
Cognitive status – AOX4
Temp – 36.9
Pulse – 62bpm, regular, normal
BP – 110/62(left), 110/62(right), normotensive, normal
Respiration – 16 bpm regular, unlabored
SPO2 – 98%
General
AOX4, well groomed, well nourished, sitting on exam table. No apparent distress
HEENT/Neck
Trachea midline, thyroid nontender, no thyromegaly, no cervical lymphadenopathy.
Cardiovascular
Regular rate, rhythm, no murmurs, gallops, or rubs. Capillary refill<3seconds
Chest/Respiratory
Normal respiratory rate, effort, excursion. Lungs clear to auscultation bilaterally. No use of accessory muscles.
Skin
Face exhibits multiple comedones, open and closed across chin, jawline, cheek, and nose areas. Additionally, numerous papules and pustules ae noted. No scarring or cystic lesions noted. Skin appears oily with visible sebum accumulation and enlarged pores. Few lesions scattered across neck, shoulders, and back. Tanner stage IV.
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