Lump 2

Name: Alicia Wilson

Age: 20 Years Old

Date of Birth: 5th May 2004

Location: GP Surgery

Occupation: Student

“I’ve been having acne ever since I hit puberty! I’d like to have it treated doctor”

• Site : Whole face, especially forehead

• Onset : Since 11-years-old

• Character : Yellow-fluid filled pustules and papules with blackheads

• Radiating : N/A

• Associated symptoms :
  1/ Erythema

• Timing : Progressively gotten worse

• Exacerbating : During menstruation

• Alleviating factors : None 

• Severity: Nil

• Psychosocial: “Doctor, I’m embarrassed as this is ruining my self-confidence”

Site: Whole face, especially forehead

Size: Multiple yellow fluid-filled bubbles of different sizes

Shape: Spherical

Surface: Variety of smooth and rough

Margins: No well-demarcated

Tenderness: No

Temperature: Normal

• Ideas/ Understanding: “Acne is something we get after puberty due to hormones."

• Expectations: “Can you give me some medications?”

• Concerns: “I am concerned about my looks as I am in the drama club”

• Otherwise, NO fever, recent infections

• NO headache, chest pain, palpitations, shortness of breath

• NO vomiting, diarrhea, abdominal pain.

• Normal urinary flow and bowel habits.

• Mood is normal, no bullying in school

"No” - Do you notice any hair follicles on your face? Irregular periods? Putting on weight?

• Suggestive of Polycystic Ovarian Syndrome (PCOS)

Previous hospital admissions: None

Previous surgeries: None

Medical conditions: None

Medications:

• None.

Over the counters:

• None.

Allergies:

• None.

• LMP: 2 weeks ago

• Frequency: Regular

• Flow: Normal, Not heavy

• Other symptoms: Otherwise, NO dysmenorrhea

• Contraceptives: NOT on any form of contraceptives

Normal and healthy family

• Smoking: Does not smoke

• Alcohol: Does not drink alcohol

• Recreational drugs: Never

• Diet: Eats a well balanced diet

• Exercise: No

• Occupation: Student