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Active encounter

Outpatient · Paediatric Clinic · Room 2

Attending: Dr. Fatuma Said · Opened -8755s ago

Record vitals New SOAP note

Blood pressure

102/64

mmHg

-9655s ago · 2 points

Pulse

94

bpm

-9655s ago · 2 points

SpO₂

98

%

-9655s ago · 2 points

Temperature

36.9

°C

-9655s ago · 1 points

Active problems1

Open
  • J45.40Moderate persistent asthmachronic

Active medications2

Open

  • Fluticasone + Salmeterol (Seretide) · 125/25 mcg

    Two puffs BD · ICS + LABA

    INH

  • Salbutamol MDI · 100 mcg

    PRN for wheeze · SABA

    INH

Allergies & reactions1

Open

  • Dust mites

    Rhinitis, Wheeze

    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, 14:30

A: Mild drift in asthma control — likely seasonal/exercise-induced.