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Active encounter

Outpatient · Cardiology Clinic · Room 3B

Attending: Dr. Majani Edward · Opened 2h ago

Record vitals New SOAP note

Blood pressure

138/84

mmHg

2h ago · 7 points

Pulse

78

bpm

2h ago · 7 points

SpO₂

97

%

2h ago · 6 points

Temperature

36.6

°C

2h ago · 6 points

Active problems5

Open
  • I10Essential hypertensionsince 28 Apr 2021chronic
  • E11.9Type 2 diabetes mellitussince 28 Apr 2023chronic
  • E78.5Hyperlipidaemia, unspecifiedsince 27 Apr 2024chronic
  • M81.0Osteoporosis, postmenopausalsince 04 Sept 2024chronic
  • J45.909Asthma, uncomplicatedchronic

Active medications6

Open

  • Amlodipine · 10 mg

    Once daily · Calcium channel blocker

    PO

  • Metformin · 1000 mg

    Twice daily · Biguanide

    PO

  • Atorvastatin · 40 mg

    Once daily at bedtime · HMG-CoA reductase inhibitor

    PO

  • Salbutamol MDI · 100 mcg

    PRN for wheeze · Short-acting β2 agonist

    INH

  • Alendronate · 70 mg

    Once weekly · Bisphosphonate

    PO

  • Aspirin · 75 mg

    Once daily · Antiplatelet

    PO

Allergies & reactions3

Open

  • Penicillin

    Urticaria, Angioedema

    anaphylaxis

  • Sulfa drugs

    Maculopapular rash

    moderate

  • Peanuts

    Throat swelling

    severe

AI insights

BP trending above target over 3 visits. Consider uptitration of anti-hypertensive.

Flu vaccine status: due. Last dose > 12 months ago.

Medication adherence inferred-high from refill cadence.

AI suggestions are draft only and never auto-applied. Clinician signs every change.

Latest SOAP note

Open
Dr. Majani Edward27 Apr 2026, 09:45

A: 1. HTN — sub-optimal control, likely contributing to headaches. 2. T2DM — reasonable control, last HbA1c 7.1%. 3. Hyperlipidaemia — on atorvastatin. 4. Osteoporosis — stable on alendronate.