Case Study 19
2:15 PM
Liang Wang
Age 13½ years
Opening Scenario
Liang Wang is a 13½-year-old female scheduled for a follow-up acne visit. Her facial blemishes have not gotten better, and she is requesting a dermatology referral.
History of Present Illness
“I was here about a month ago for a camp physical. I was started on erythromycin 2% topical twice a day after cleansing with benzoyl peroxide 5%. I didn’t feel that I was having any results after three weeks, so I tried some Cleocin T that had been prescribed for one of my friends. Cleocin T was only slightly more effective than erythromycin. I do not want another topical; another friend of mine had a pill and that worked much better. I have been avoiding chocolate because my mother told me I should, and that seems to have helped a little.” Her blemishes do not change related to menses. She has a few areas of acne on her back, but it is mostly on her face and chin.
Medical History
No hospitalizations or accidents. Immunizations up to date, including Tdap and HPV.
Family Medical History
MGM: DM, onset at about 60 years old
Mother: 33 years old (A&W)
Father: 34 years old (A&W)
MGF, PGF, PGM: A&W
Social History
High school student. Plays soccer. Academically strong. Attends dances. Denies current sexual activity. Denies any alcohol use. Is a nonsmoker.
75
Medications
Erythromycin and Cleocin T as described under HPI
Allergies
NKDA
Review of Systems
General: Denies fatigue, night sweats, no change in weight
HEENT: Denies diplopia, blurring, hearing impairment, sore throats, headaches; dental examination three months ago
Cardiovascular: Denies chest pain, palpitations, exercise intolerance. Denies excessive bruising.
Respiratory: Denies shortness of breath, dyspnea on exertion
Gastrointestinal: Denies anorexia, nausea, vomiting, constipation, diarrhea, black or clay-colored stools
Genitourinary: Notes that her periods are somewhat irregular with alternating every 28 days and the next about every 42 days, 5-day duration; denies heavy bleeding; menarche at age 11; denies dysuria, hematuria
Musculoskeletal: Denies joint or back pain, no trauma
Physical Examination
Camp Physical Examination for Liang Wang from One Month Ago
General: Appears stated age and healthy; skin of face has a moderate distribution of comedones and a few cysts; back comedones are also present
Vital signs: Temperature 97.4° F; pulse 66 bpm; respirations 16/min; BP 90/38 mm Hg
Height: 5 ft 1 in; weight: 97 lb; BMI: 18.3
HEENT: Head is normocephalic, atraumatic; pupils equal, round, and reactive to light; extraocular movements intact; tympanic membranes are observable without excessive cerumen; nares are patent without redness or exudate; throat is not injected, tongue is midline; palate rises symmetrically; teeth are in adequate repair; multiple facial comedones, a few of which are cystic
Neck: Supple without thyromegaly, adenopathy, or carotid bruits
Heart: Regular rate and rhythm; no murmurs, rubs, or gallops
Lungs: Clear to auscultation and percussion
Breasts: Examination is deferred related to age and indications
Back and chest: A few comedones
76
Abdominal: Soft, nontender; no hepatosplenomegaly
Extremities: No cyanosis, clubbing, or edema
Neurological: Reflexes are 2+ at the biceps, triceps, brachioradialis, patellar, and Achilles; no Babinski signs present; strength and sensation are symmetrical
After reviewing the case and the Grading Criteria in Appendix A, jot down your notes or preliminary answers in the spaces provided below. When you are ready to submit your answers for grading (if you are working with an instructor) and reflective feedback to help you evaluate your answers, go to http://www.evolve.elsevier.
Learning Issues
Before identifying your recommended Assessment and Plan, identify any learning issues that you believe are important for you to explore about this case:
Assessment
Please indicate the problems or issues you have identified that will guide your care (preferably in list form):
77
Plan
Please list your plans for addressing each of the problems or issues in your assessment:
NSG 5540 CASE STUDY TEMPLATE
Title page – including the identified case study name and number
1. Learning Issues – what do you need more information in order to develop a plan? If so, what information do you need or want? (Can be bullet points)
1. Example – Chest Pain
1. How do you evaluate a patient with a history of chest discomfort and risk factors for heart disease?
2. What are the laboratory findings that are important to look for with someone with chest discomfort?
* How do you manage abnormal lipids?
1. What lifestyle changes are important to recommend to reduce cardiac risk
2. Interpretation of Cues, Patterns, and Informati
2:15 PM
Liang Wang
Age 13½ years
Opening Scenario
Liang Wang is a 13½-year-old female scheduled for a follow-up acne visit. Her facial blemishes have not gotten better, and she is requesting a dermatology referral.
History of Present Illness
“I was here about a month ago for a camp physical. I was started on erythromycin 2% topical twice a day after cleansing with benzoyl peroxide 5%. I didn’t feel that I was having any results after three weeks, so I tried some Cleocin T that had been prescribed for one of my friends. Cleocin T was only slightly more effective than erythromycin. I do not want another topical; another friend of mine had a pill and that worked much better. I have been avoiding chocolate because my mother told me I should, and that seems to have helped a little.” Her blemishes do not change related to menses. She has a few areas of acne on her back, but it is mostly on her face and chin.
Medical History
No hospitalizations or accidents. Immunizations up to date, including Tdap and HPV.
Family Medical History
MGM: DM, onset at about 60 years old
Mother: 33 years old (A&W)
Father: 34 years old (A&W)
MGF, PGF, PGM: A&W
Social History
High school student. Plays soccer. Academically strong. Attends dances. Denies current sexual activity. Denies any alcohol use. Is a nonsmoker.
75
Medications
Erythromycin and Cleocin T as described under HPI
Allergies
NKDA
Review of Systems
General: Denies fatigue, night sweats, no change in weight
HEENT: Denies diplopia, blurring, hearing impairment, sore throats, headaches; dental examination three months ago
Cardiovascular: Denies chest pain, palpitations, exercise intolerance. Denies excessive bruising.
Respiratory: Denies shortness of breath, dyspnea on exertion
Gastrointestinal: Denies anorexia, nausea, vomiting, constipation, diarrhea, black or clay-colored stools
Genitourinary: Notes that her periods are somewhat irregular with alternating every 28 days and the next about every 42 days, 5-day duration; denies heavy bleeding; menarche at age 11; denies dysuria, hematuria
Musculoskeletal: Denies joint or back pain, no trauma
Physical Examination
Camp Physical Examination for Liang Wang from One Month Ago
General: Appears stated age and healthy; skin of face has a moderate distribution of comedones and a few cysts; back comedones are also present
Vital signs: Temperature 97.4° F; pulse 66 bpm; respirations 16/min; BP 90/38 mm Hg
Height: 5 ft 1 in; weight: 97 lb; BMI: 18.3
HEENT: Head is normocephalic, atraumatic; pupils equal, round, and reactive to light; extraocular movements intact; tympanic membranes are observable without excessive cerumen; nares are patent without redness or exudate; throat is not injected, tongue is midline; palate rises symmetrically; teeth are in adequate repair; multiple facial comedones, a few of which are cystic
Neck: Supple without thyromegaly, adenopathy, or carotid bruits
Heart: Regular rate and rhythm; no murmurs, rubs, or gallops
Lungs: Clear to auscultation and percussion
Breasts: Examination is deferred related to age and indications
Back and chest: A few comedones
76
Abdominal: Soft, nontender; no hepatosplenomegaly
Extremities: No cyanosis, clubbing, or edema
Neurological: Reflexes are 2+ at the biceps, triceps, brachioradialis, patellar, and Achilles; no Babinski signs present; strength and sensation are symmetrical
After reviewing the case and the Grading Criteria in Appendix A, jot down your notes or preliminary answers in the spaces provided below. When you are ready to submit your answers for grading (if you are working with an instructor) and reflective feedback to help you evaluate your answers, go to http://www.evolve.elsevier.
Learning Issues
Before identifying your recommended Assessment and Plan, identify any learning issues that you believe are important for you to explore about this case:
Assessment
Please indicate the problems or issues you have identified that will guide your care (preferably in list form):
77
Plan
Please list your plans for addressing each of the problems or issues in your assessment:
NSG 5540 CASE STUDY TEMPLATE
Title page – including the identified case study name and number
1. Learning Issues – what do you need more information in order to develop a plan? If so, what information do you need or want? (Can be bullet points)
1. Example – Chest Pain
1. How do you evaluate a patient with a history of chest discomfort and risk factors for heart disease?
2. What are the laboratory findings that are important to look for with someone with chest discomfort?
* How do you manage abnormal lipids?
1. What lifestyle changes are important to recommend to reduce cardiac risk
2. Interpretation of Cues, Patterns, and Informati
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