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Active encounter

Inpatient · Ward 4A · Bed 12

Attending: Dr. Fatuma Said · Opened 2d ago

Record vitals New SOAP note

Blood pressure

108/62

mmHg

6h ago · 6 points

Pulse

96

bpm

6h ago · 6 points

SpO₂

92

%

6h ago · 6 points

Temperature

36.4

°C

6h ago · 6 points

Active problems4

Open
  • I50.9Heart failure, unspecifiedchronic
  • N18.4Chronic kidney disease, stage 4chronic
  • I48.91Atrial fibrillationchronic
  • M17.11Osteoarthritis, right kneechronic

Active medications5

Open

  • Furosemide · 40 mg

    Once daily · Loop diuretic

    PO

  • Bisoprolol · 2.5 mg

    Once daily · β-blocker

    PO

  • Ramipril · 2.5 mg

    Once daily · ACE inhibitor

    PO

  • Warfarin · 3 mg

    Once daily, dose per INR · Anticoagulant

    PO

  • Paracetamol · 1 g

    QDS PRN · Analgesic

    PO

Allergies & reactions1

Open

  • Codeine

    Nausea, Pruritus

    moderate

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. Fatuma Said27 Apr 2026, 07:30

A: Decompensated heart failure — responding to diuresis. AF with rapid ventricular response stabilising. CKD stage 4 — creatinine stable.