A 15yr old school student work part-time with Hx of acne.

For which was commenced on a kit

(clindamycin solution evening and washing gel morning). It works but b4 her menses period
experience acne (Premenstrual flare). Not sexually active and parents believe sex after
marriage. She tells you that her friends in school use OCP for their acne and its good. She also
wants OCP.
1. What are the most considerations (CI) in this case
2. What are the issues (like cost, side effects).
3. What will be your approach.
4. What will you consider b4 giving OCP.

*Acne examination and how to treat acne/

* acne requesting OCP mature minor/ Gillic competency.
*Acne for head examination.

Hx:
Welcome, ask preferred name after introducing myself, establish rapport, ensure confidentiality
by saying everything will be confidential between me and you until yours or others health is at
risk. Look at face of my pt if she looks depressed or anxious about anything.
Try to explore any hidden agenda by asking she came for acne or any other issue. Then start by
asking open ended question would you like to tell me something more about yourself. Is it first
time that you are having this problem, since when or in the past also. Any prolonged use of skin
care products/ cosmetics/ heavy makeup. Did she visit any other GP or specialist for this or
using any medicine like over the counter medicine or herbal medicine, eps. steroids or anti-
epileptics (e.g. phenytoin). Any allergies to any medicine. Any H/O excessive sun exposure/ sun-
burn. Any HO repeated look into mirror.
When was LMP, periods regular or any intermenstrual bleed. Any change in ACNE before or
during menstruation (pre menstrual flare up).
Are you sexually active if yes, do you have regular sexual partner. How many partners your
partner have. Partner male or female. What is age of partner and relationship with partner.
Occupation of partner. What is preferred mode of sex, like anal oral or vaginal. Any STI before.
Do you practice safe sex. Any use of contraceptive methods like condoms or pills. Any PID or
discharge. Any pelvic surgery. Test of neck of womb (don’t ask it starts at age 25 in sexullay
active women). Any abnormal weight gain or abnormal hair growth pattern ---- to rule out
PCOs?. Any chest pain, SOB or leg pain, headache (migraine with aura). Any H/O high BP or
high Blood sugar. Any H/O clotting disorders or stoke.
How is she living? Living alone or living with parents. Who is supporting her financially? Does
she do any job or dependant on family financially. Any family H/O Breast CAs

HEADSS Screening.
SADMA TOI. Ask about Human Papiloma Virus & Hep-B vaccination.
How is mood, does she still enjoy activities she used to enjoy before. Any past H/O depression.
Discuss about cost issues (its imp) like she can afford to buy expensive medicine like Diane 35 as
compliance is a big issue as she may get pregnant.

Gillick Competency Check:

Living alone or with family. Any job is she doing or dependant on family. Ask him few questions
if she knows about ACNE, from she came to know about OCPs and contraception if she knows
these she is mature minor.
Also age of boy friend and relationship with her like class fellow. Any superiority or power like
teacher couch, tutor or religious instructor (is considered abuse).
For PESCI: after asking about Gillick competency and independence as she is doing part-time
job. Then double check it with supervisor.
Physical Exam from examiner

1-General appearance
-What is the BMI?
-Any pallor, icterus, cyanosis, lymph node enlargement, edema, poor skin turgor, dry mucous
membranes, delayed capillary refill time?
- Any edema or tenderness of the lower leg?
2-Vital signs
What is the BP, PR, RR, Temp and O2 Sats of my patient?
Examine face for severity, pattern and extent of acne. See type like papule, pustules or cysts.
On face only or other parts of body are also involved like neck, chest or forehead. Then use
dermatoscope and take swab if any evidence of ooze or discharge from lesion
3-quick chest and heart
how are the heart sounds? Is the rhythm regular? Any murmurs?
Is air entry equal? Any abnormal breath sounds?
4-breast
Any palpable breast lumps or tenderness?
4-CNS
How is the motor and sensory exam of the upper and lower limbs? (stroke symptoms)
5-Abdominal examination
Any distention or mass of the abdomen? Is there any hepatosplenomegaly, any mass or
tenderness?
6-Pelvic examination (just inspection)
Are there any visible lesions in the vulva and vagina? Any discharge or bleeding?
7-office tests
I'd like to do a urine dipstick test and a blood sugar level.
Thank you for those information. I'd speak with my patient again.
Diagnosis and Management
1-OCP mechanism of action
-Okay, it seems like it would be possible for you to start on combined OCPs, so I would like to
give you information about it.
-Combined OCPs contain 2 hormones, estrogen and progesterone which is normally present in
your body which regulates your periods.
-it inhibits ovulation, the release of egg from the ovary. To a lesser extent, it increases the
thickness of your cervical secretions so the sperm will find it difficult to get through. And just in
case fertilization happens, it changes the lining of your womb so that implantation does not
happen.

2-Dose
(TAKE PILL PACK)
In a pill pack, there are 28 pills, 21 are hormonal pills, 7 are sugar-coats or dummy pills. Starting
taking the hormonal pill from the 1st day of your next period, 1 pill a day, at the same time
everyday.
-Continue the hormonal pills for 21 days and then on starting the sugar pills, you will get your
periods (withdrawal bleed).
-However if you want to start taking the pill right away without waiting for your next period,
you may, but use alternate methods like condoms for 7 days.
3-Side effects (minor and major)
While taking the pill, you may experience side effects such as:
-Minor SE like nausea and vomiting, abdominal bloating and breast tenderness.
-Breakthrough bleeding or bleeding in between periods will usually settle in 3-4 months.
-Major side effects such as DVT, stroke, PE and MI could happen but are rare with low dose
pills, such as what you will be taking.
4-Advantages
Advantages of the pill include:
- periods become more regular, lighter and shorter.
- There is less dysmenorrhea.
- There is decreased incidence of benign breast lumps and pelvic inflammatory diseases,
- decreased incidence of endometrial, colon and ovarian cancer, and thyroid disorders.
5-Disadvantages
However, you must remember that OCPs do not protect against sexually transmitted
infections, so you must use condoms along with it just in case you're concerned about STIs.
6-Missed pill (imp)
-there will be a leaflet that come with the pills
-if you missed a pill of less than 24 hours (late pill) just take the recently missed pill As soon as
you remember and keep going with the rest even if it means taking 2 pills on the same day.
-if you miss a pill for more than 24 hours (missed pill), take the recently missed pill and just
keep going with the rest even if it means taking 2 pills on the same day.
-If you keep going with the rest, and the dummy pill period falls within 7 days of missing the pill,
skip taking the dummy pills and start the hormonal pills from the next pack. This will mean that
you will miss having your periods. Alternate methods of contraception like condoms should be
used for 7 days after missing the pill.
• If she had missed her pill (18-19-20) and 21st day she remembered, take the 20th pill and
21st pill, on 22nd day due for dummy pills, skip the dummy pills and start taking the
hormonal pills from the next pack.
• You have to use an alternate of method of contraception after missing period.