C09991215 / invoice 10000

Reason: Recheck + Meds (Cream) +AG'sHistory:-O brought P in for recheck for DLE-been under managed with tacrolimus cream, well controlled-had an accident with hit by cricket bat and nose had wound and bleeding non-stop; went straight to clinic and did surgery; healed very well -EDUF normal, no V/D-no others concernExamination:Mentation: BARBody condition score: 3/5MM: p,m            CRT: 1 secHR: 120                RR: pant LN: wnlTemperature: not takenDental NAD Cardiovascular: NAD- no heart murmur or arrhythmiasRespiratory: NAD- no resp depression or effortAbdo: NAD MSK NAD Pink smooth nose with no superficial skin lesions Both ag moderately full with normal liquid discharge, expressedAssessment:-well patient, with controlled DLETreatment:-tacrolimus 0.1% ointment BID Plan:-happy to dispense for another 6 months    Vital Signs    Weight: 35.6;