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RN

Rashitha Nalaranga

Patient ID: PAT001
Age: 40
Gender: Male
Blood Group: B+
Phone: +94771234567

1

Clinical Notes

2

Prescriptions

2

Lab Orders

2

Radiology Orders

Recent Vital Signs

Recorded: 22 Sep 2025 01:12
Temp: 37.1°C
BP: 145/92
HR: 85 bpm
SpO2: 97%
Weight: 75.80 kg
BMI: 25.61

Clinical Notes

SOAP Note

by Dr. Dr. Sarah Johnson • 22 Sep 2025 01:12

SOAP
DIAGNOSIS:

Hypertension with chest discomfort

SUBJECTIVE:

Patient complains of chest discomfort and mild shortness of breath on exertion for the past 3 days. No chest pain at rest.

OBJECTIVE:

Alert and oriented. Heart rate regular, no murmurs. Lungs clear bilaterally. No peripheral edema.

ASSESSMENT:

Likely related to hypertension. Need to monitor blood pressure and adjust medication if needed.

PLAN:

Continue current antihypertensive. Follow-up in 2 weeks. Order ECG and echo if symptoms persist.

Prescriptions

RX004001

Dr. Dr. Sarah Johnson • 22 Sep 2025

Pending
Medications:
Lisinopril 10mg - 1 tablet daily (morning)
Amlodipine 5mg - 1 tablet daily (evening)
Aspirin 75mg - 1 tablet daily (after dinner)
Instructions: Take with food. Monitor blood pressure regularly.
RX001

Dr. Dr. Sarah Johnson • 21 Sep 2025

Pending
Medications:
Paracetamol 500mg - 2 tablets, Amoxicillin 250mg - 1 capsule
Instructions: Take after meals

Medical History

Hypertension

Onset: 15 Jan 2020 • Severity: Moderate

Started on ACE inhibitors in 2020

Active

Migraine

Onset: 12 May 2018 • Severity: Moderate

Sumatriptan for acute episodes

Active

Allergies & Alerts

No known allergies

Lab Orders

LAB004001

Dr. Dr. Sarah Johnson • 22 Sep 2025

Ordered
Complete Blood Count (CBC)
Lipid Profile
Kidney Function Test (Creatinine, BUN)
Electrolytes (Na, K, Cl)
LAB001

Dr. Dr. Sarah Johnson • 21 Sep 2025

Ordered
Complete Blood Count, Lipid Profile

Radiology Orders

RAD004001

Dr. Dr. Sarah Johnson • 22 Sep 2025

Ordered
Chest X-Ray - Chest
Chest discomfort, rule out cardiac enlargement
RAD001

Dr. Dr. Sarah Johnson • 21 Sep 2025

Ordered
X-Ray - Chest
Routine cardiac checkup

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