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Clinical profile

Structured clinical history — signed, auditable, and ready for any covering clinician.

Allergies & adverse reactions

3

Penicillin

since 12 Jun 2008

Urticaria, Angioedema

anaphylaxisDrug

Dr. Neema Lyimo

27 Apr 2025

Sulfa drugs

Maculopapular rash

moderateDrug

Dr. Neema Lyimo

27 Apr 2025

Peanuts

Throat swelling

severeFood

—

Problem list

6
I10Essential hypertensionOnset 28 Apr 2021chronicactive
E11.9Type 2 diabetes mellitusOnset 28 Apr 2023chronicactive
E78.5Hyperlipidaemia, unspecifiedOnset 27 Apr 2024chronicactive
M81.0Osteoporosis, postmenopausalOnset 04 Sept 2024chronicactive
J45.909Asthma, uncomplicated—chronicactive
N39.0UTI — resolved27 Jan 2026resolved

Medications

6

Amlodipine · 10 mg

Take 1 tablet by mouth every morning

Once dailyCalcium channel blockerStart 23 Mar 2025Dr. Majani Edward3 refills

Metformin · 1000 mg

Take 1 tablet by mouth twice daily with meals

Twice dailyBiguanideStart 09 Nov 2023Dr. Majani Edward5 refills

Atorvastatin · 40 mg

Once daily at bedtime

Once daily at bedtimeHMG-CoA reductase inhibitorStart 04 Sept 2024Dr. Majani Edward2 refills

Salbutamol MDI · 100 mcg

PRN for wheeze

PRN for wheezeShort-acting β2 agonistStart 13 Dec 2024Dr. Fatuma Said6 refills

Alendronate · 70 mg

Once weekly

Once weeklyBisphosphonateStart 01 Jul 2025Dr. Majani Edward4 refills

Aspirin · 75 mg

Once daily

Once dailyAntiplateletStart 01 Feb 2025Dr. Majani Edward11 refills

Surgical history

2

Laparoscopic cholecystectomy

22 Jul 2018

Dr. Omar Juma

Muhimbili NH

Caesarean section

03 May 1992

Dr. Amelia Kihaule

Bugando MC

Social history

Tobacco

Never

Alcohol · AUDIT-C

Occasional

2 drinks / week · AUDIT-C 2

Physical activity

3 × 30 min

Walking

Occupation

Retired teacher

Education: University degree

Housing

Stable

Marital: Widowed

Substance use

Denies any recreational drug use.

Code status & advance directives

Full Code

Attested by Dr. Majani Edward on 29 Oct 2025.

Surrogate decision-maker: Zainab Mwinyi (Daughter)

Advance directive on file

POLST / MOLST attachment: not uploaded. Upload a scanned document or use the in-app attestation workflow to formalise.