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Clinical profile

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

Allergies & adverse reactions

0

No known allergies

Confirmed by attending — signed on record.

Problem list

2
J30.1Allergic rhinitis due to pollenchronicactive
M54.5Low back pain, mechanicalOnset 26 Feb 2026acuteactive

Medications

2

Loratadine · 10 mg

Once daily PRN

Once daily PRNAntihistamineStart 09 Oct 2025Dr. Neema Lyimo2 refills

Ibuprofen · 400 mg

TDS PRN

TDS PRNNSAIDStart 08 Mar 2026Dr. Neema Lyimo0 refills

Surgical history

0
No surgical history recorded

Social history

Tobacco

Former

3.0 pack-yearsquit 01 Feb 2019

Alcohol · AUDIT-C

Regular

8 drinks / week · AUDIT-C 4

Physical activity

5 × 45 min

Running, gym

Occupation

Software engineer

Education: Master's degree

Housing

Stable

Marital: Married

Substance use

Denies.

Code status & advance directives

Full Code

Attested by Dr. Neema Lyimo.

Surrogate decision-maker: Eunice Rotich (Wife)

Advance directive on file

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