Demo EMR

Current encounter is captured from Vitals, History, Diagnosis, Investigations and Medication.

Previous Encounters

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12 Feb 2026 Chief Complaint: Low back pain after long-distance driving Diagnosis: Mechanical low back pain; history of NSAID-related ulcer bleed

ProviderDr. Achieng Otieno (Medical Outpatient Clinic)

SubjectiveLower back pain for 5 days after several Nairobi-Kisumu trips. No limb weakness, numbness, bladder symptoms or fever. Requests the same pain tablets he used before, but chart shows prior diclofenac-associated upper GI bleed.

ObjectiveBP 136/84 mmHg, afebrile, normal gait, lumbar paraspinal tenderness, negative straight leg raise, no neurological deficit.

AssessmentMechanical low back pain. Important medication risk: avoid non-selective NSAIDs because of documented peptic ulcer bleed in Dec 2025.

PlanParacetamol, topical analgesic, heat therapy and physiotherapy advice. Avoid ibuprofen, diclofenac and naproxen unless senior review and gastroprotection are documented.

20 Jan 2026 Chief Complaint: Review after peptic ulcer bleed Diagnosis: Healing gastric ulcer; NSAIDs contraindicated

ProviderDr. Brian Kiptoo (Gastroenterology Clinic)

SubjectiveNo further melaena, dizziness or vomiting blood. Completed H. pylori eradication and takes omeprazole as prescribed. Has stopped buying diclofenac over the counter.

ObjectiveBP 124/78 mmHg, conjunctiva pink, abdomen soft and non-tender, Hb improved from 9.8 g/dL to 12.1 g/dL.

AssessmentRecovering NSAID-associated gastric ulcer bleed; high risk of recurrent GI bleeding with NSAIDs or aspirin.

PlanContinue omeprazole to complete 8 weeks. Document NSAID contraindication prominently. Use paracetamol first line for pain and avoid self-medication.

17 Dec 2025 Chief Complaint: Black stool and epigastric pain Diagnosis: Upper GI bleed from NSAID-associated peptic ulcer disease

ProviderDr. Achieng Otieno (Casualty)

SubjectiveTwo episodes of black stool, epigastric burning and light-headedness. Had taken diclofenac 50 mg TDS for knee pain for 6 days from a chemist. No alcohol binge.

ObjectivePulse 102 bpm, BP 104/68 mmHg, mild epigastric tenderness, stool occult blood positive, Hb 9.8 g/dL.

AssessmentUpper GI bleed, likely NSAID-associated peptic ulcer disease.

PlanStop diclofenac and all NSAIDs, start IV then oral PPI, test and treat H. pylori, repeat Hb, counsel patient to disclose ulcer bleed before receiving pain medicine.

05 Oct 2025 Chief Complaint: Right knee pain Diagnosis: Patellofemoral knee pain

ProviderDr. Mercy Wanjiku (Outpatient Clinic)

SubjectiveAnterior right knee pain after long sitting and climbing stairs. Works as a matatu driver. No trauma, swelling, fever or locking.

ObjectiveFull range of motion, mild patellar grind tenderness, no effusion, ligaments stable.

AssessmentPatellofemoral knee pain related to prolonged sitting and deconditioning.

PlanParacetamol as needed, quadriceps strengthening, weight control advice and review if swelling or locking develops.

22 Jul 2025 Chief Complaint: New patient wellness visit Diagnosis: Overweight; no chronic diagnosis documented

ProviderDr. Mercy Wanjiku (Outpatient Clinic)

SubjectiveRegistered at clinic near stage for routine check. No known diabetes, hypertension, asthma, TB treatment or HIV care. Occasional alcohol on weekends, non-smoker.

ObjectiveBP 128/82 mmHg, BMI 29.0, random blood sugar 5.8 mmol/L, HIV self-test reported negative within the year.

AssessmentOverweight with occupational risk for musculoskeletal pain from prolonged driving.

PlanLifestyle counselling, baseline screening labs offered, encourage scheduled breaks, stretching and follow-up as needed.

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