Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Dermatology
Sample Name: Acne Vulgaris

Description: A simple note on Acne Vulgaris.
(Medical Transcription Sample Report)

ACNE VULGARIS, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life. The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.

SIGNS AND SYMPTOMS:
* Blackheads the size of a pinhead.
* Whiteheads similar to blackheads.
* Pustules - lesions filled with pus.
* Redness and inflamed skin.
* Cysts - large, firm swollen lesions in severe acne.
* Abscess - infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.

CAUSES:
Oil glands in the skin become plugged for reasons unknown but during adolescence, sex-hormone changes play some role. When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection. Acne is NOT caused by foods, uncleanliness or masturbation. Cleaning the skin can decrease its severity but sexual activity has no effect on it. A family history of acne can indicate if an individual will get acne and how severe it might be. Currently, acne can't be prevented.

ACNE CAN BE BROUGHT ON OR MADE WORSE BY:
* Hot or cold temperatures.
* Emotional stress.
* Oily skin.
* Endocrine (hormone) disorder.
* Drugs such as cortisones, male hormones, or oral contraceptives.
* Some cosmetics.
* Food sensitivities. Again, foods do not cause acne but some certain ones may make it worse. To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time. If acne worsens 2-3 days after consumption, then avoid this food. Acne usually improves in summer so some foods may be tolerated in summer that can't be eaten in winter.

TREATMENT:
* Most cases of acne respond well to treatment and will likely disappear once adolescence is over. Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.
* If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3- 5 minutes; an antibacterial soap may work better. A previously used wet washcloth will harbor bacteria. Don't aggressively scrub tender lesions as this may spread infection; be gentle. Rinse the soap off for a good 1-2 minutes. Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.

OTHER TIPS THAT MAY HELP ACNE:
* Shampoo hair at least twice a week. Keep hair off of face even while sleeping as hair can spread oil and bacteria. If you have dandruff, use a dandruff shampoo. Avoid cream hair rinses.
* Wash sweat and skin oil off as soon as possible after sweating and exercising.
* Use thinner, water-based cosmetics instead of the heavier oil-based ones.
* Avoid skin moisturizers unless recommended by your doctor.
* Do not squeeze, pick, rub or scratch your skin or the acne lesions. This may damage the skin causing scarring and delay healing of acne. Only a doctor should remove blackheads.
* Keep from resting face on hands while reading, studying or watching TV.
* Try to avoid pressing the phone receiver on you chin while talking on the phone.
* Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe! Don't use the sun to treat acne.
* Dermabrasion may be another option to treat acne scars. This is a type of cosmetic surgery to help remove unsightly scars.

MEDICATIONS THAT MAY BE PRESCRIBED TO HELP ACNE INCLUDE:
* Oral or topical antibiotics.
* Cortisone injections into acne lesions.
* Oral contraceptives.
* Tretinoin, which may increase sun sensitivity and excessive dryness, is not recommended during pregnancy.
* Accutane (isotretinoin) is a powerful drug to treat acne but causes birth defects. A woman taking this drug
must be on two types of birth control and have negative pregnancy tests. This drug also increases sun
sensitivity. Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.

TETRACYCLINE:
Tetracycline is a very safe antibiotic. It is not related to penicillin and an allergy to it is unusual. There are several potential side effects:
1. Tetracycline can cause nausea or heartburn.
2. Tetracycline can cause vaginitis.
3. Tetracycline can cause excessive sun burn.

CAUTIONS ON TETRACYCLINE:
1. Do not take Tetracycline with milk or milk products (ice cream, cheese, yogurt, etc.). This will cancel out the Tetracycline. Separate the Tetracycline from these products by one and one-half hours before and after each capsule. Do have a small amount of non milk-containing food in your stomach first to prevent nausea.
2. Do not take Tetracycline if you are pregnant.
3. Do not take Tetracycline if you are taking birth control pills unless specifically instructed to do so.
4. If at the beach or skiing in the sun, use an effective sunblock (SPF-15 or greater) to prevent burning.

Keywords: dermatology, acne vulgaris, skin, blackheads, whiteheads, pustules, abscess, oily skin, sun sensitivity, inflammation, tetracycline, vulgaris, soap, cleaning, acne,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples