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KP

Kasun Perera

Patient ID: PAT003
Age: 36
Gender: Male
Blood Group: A+
Phone: +94771234571

1

Clinical Notes

2

Prescriptions

0

Lab Orders

0

Radiology Orders

Recent Vital Signs

Recorded: 22 Sep 2025 01:12
Temp: 36.5°C
BP: 118/75
HR: 72 bpm
SpO2: 99%
Weight: 62.00 kg
BMI: 24.22

Clinical Notes

Consultation Note

by Dr. Dr. Emily Davis • 22 Sep 2025 01:12

Consultation
DIAGNOSIS:

Contact Dermatitis

SUBJECTIVE:

Patient presents with itchy rash on forearms and neck for 1 week. Worse at night. No known allergies.

OBJECTIVE:

Erythematous papular rash on bilateral forearms and posterior neck. No scaling or vesicles. No lymphadenopathy.

ASSESSMENT:

Contact dermatitis, possibly allergic. Need to identify trigger.

PLAN:

Topical steroid cream BD for 1 week. Antihistamine at bedtime. Avoid potential irritants. Review in 1 week.

Prescriptions

RX003

Dr. Dr. Emily Davis • 22 Sep 2025

Pending
Medications:
Antiseptic Solution - Apply topically
Instructions: Clean affected area twice daily
RX004003

Dr. Dr. Emily Davis • 22 Sep 2025

Pending
Medications:
Hydrocortisone cream 1% - Apply thin layer twice daily
Cetirizine 10mg - 1 tablet at bedtime
Calamine lotion - Apply as needed for itching
Instructions: Apply cream to affected areas only. Avoid face.

Medical History

Asthma

Onset: 10 Mar 2015 • Severity: Mild

Salbutamol inhaler as needed

Active

Allergies & Alerts

No known allergies

Lab Orders

No lab orders

Radiology Orders

No radiology orders

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