CO
GK
Grace Kamau F · 34y · MRN: NWH-2024-0847
Penicillin T2 Diabetes Hypertension
4 Active Meds In Consultation HIS Record

Procedures

Today
Venipuncture — Blood Draw
Diagnostic · CO Muthoni · Completed
Today, 09:15 AM Done
  • CBC, BMP, and HbA1c samples collected from left antecubital fossa
  • Patient tolerated procedure well; no bleeding, haematoma, or adverse reaction
  • Samples labelled and sent to lab
Direct Ophthalmoscopy
Diagnostic · CO Muthoni · Completed
Today, 10:10 AM Done
  • Bilateral fundoscopy performed with handheld ophthalmoscope
  • No papilledema, no haemorrhages, no exudates
  • Cup-to-disc ratio normal bilaterally. Retinal vessels unremarkable
  • Findings consistent with normal fundoscopic exam; no signs of hypertensive retinopathy
Serial BP Measurement
Monitoring · CO Muthoni · Completed
Today, 10:20 AM Done
  • Three serial readings taken at 5-minute intervals (right arm, seated, appropriate cuff size)
  • Reading 1: 154/96 mmHg · Reading 2: 152/94 mmHg · Reading 3: 150/92 mmHg
  • Average: 152/94 mmHg — confirmed elevated above target (<140/90)
Previous (This Encounter)
Random Blood Glucose (POCT)
Point-of-Care · CO Muthoni
10 Feb, 08:45 AM Done
  • Fingerstick glucose using glucometer: 156 mg/dL (non-fasting)
  • Confirmed with subsequent fasting glucose order (BMP panel)