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Active encounter

Outpatient · General Clinic · Room 1A

Attending: Dr. Neema Lyimo · Opened 34m ago

Record vitals New SOAP note

Blood pressure

124/78

mmHg

24m ago · 3 points

Pulse

68

bpm

24m ago · 3 points

SpO₂

99

%

24m ago · 2 points

Temperature

36.7

°C

24m ago · 1 points

Active problems2

Open
  • J30.1Allergic rhinitis due to pollenchronic
  • M54.5Low back pain, mechanicalsince 26 Feb 2026acute

Active medications2

Open

  • Loratadine · 10 mg

    Once daily PRN · Antihistamine

    PO

  • Ibuprofen · 400 mg

    TDS PRN · NSAID

    PO

Allergies & reactions0

Open

No known allergies

Confirmed by attending

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. Neema Lyimo27 Apr 2026, 11:25

A: Mechanical low back pain, improving.