Medical Records

Chief Complaint: Skin rash on forearms for 2 weeks

History: Patient reports dry, itchy patches appearing on bilateral forearms. No known triggers identified. No fever or systemic symptoms.

Examination: Erythematous, dry patches with mild scaling noted on bilateral forearms. No signs of infection.

Assessment: Mild atopic dermatitis (eczema)

Plan:
1. Hydrocortisone 1% cream BID for 2 weeks
2. Moisturize frequently with fragrance-free lotion
3. Avoid harsh soaps and hot water
4. Follow-up in 4 weeks if not improved

Complete Blood Count (CBC): Normal
Comprehensive Metabolic Panel: Normal
Lipid Panel:
- Total Cholesterol: 195 mg/dL (Desirable)
- LDL: 118 mg/dL (Near optimal)
- HDL: 58 mg/dL (Good)
- Triglycerides: 95 mg/dL (Normal)

Hemoglobin A1C: 5.4% (Normal)
TSH: 2.1 mIU/L (Normal)
Vitamin D: 42 ng/mL (Sufficient)