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Kelly Doe

15/01/2026

Consultation case note

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Assessment: ...
Plan: ...

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Laboratory report (PDF)

PDF

14/01/2026

Fundus photograph (image)

Image

Chest X-ray (image)

Image

Follow-up note

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13/01/2026

Medication reconciliation note

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Vitals check-in

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

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12/01/2026

Telephone triage note

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Plan: ...

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Note

09/01/2026

Specialist referral letter (PDF)

PDF

06/01/2026

Discharge summary note

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Assessment: ...
Plan: ...

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01/01/2026

Care plan update

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Objective: ...
Assessment: ...
Plan: ...

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25/12/2025

Initial intake note

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

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Note

Recent Visits Summary

🧾 Visit overview

Kelly Doe attended for follow-up review. Symptoms are improving overall with intermittent fatigue and mild headaches.

🔎 Key findings

Vitals stable; no acute distress reported
Lab trend: mild abnormalities noted; recommend recheck as planned
Imaging: no urgent findings flagged in latest report

🗓️ Plan (next 2–4 weeks)

Continue current management and monitor symptoms
Repeat labs if symptoms worsen or per follow-up schedule
Safety net: seek urgent care for chest pain, persistent fever, worsening shortness of breath, new neuro deficits

Patient Background

🪪 Demographics

Name: Kelly Doe
Gender: Female
DOB: 1987-03-14
NRIC: S8723456D

Summary

Summary compiled from the most recent notes, lab report, and uploaded imaging. This is a working clinical snapshot intended to help you quickly orient; confirm details against source documents.

Past medical history: hypertension; type 2 diabetes mellitus; hyperlipidemia; seasonal allergic rhinitis
Past surgical history: laparoscopic appendectomy (2016)
Current concerns: intermittent fatigue and mild headaches over the last 2–3 weeks; here for follow-up review

💊 Medication list (from notes)

Amlodipine 5 mg PO daily
Metformin XR 500 mg PO nightly with food
Atorvastatin 10 mg PO nightly
Cetirizine 10 mg PO PRN allergies
Paracetamol 1 g PO PRN headache/fever (max 4 g/day)

Social & Family History

🏠 Social history

Living situation: lives with spouse; independent with ADLs
Occupation: office administrator (mostly sedentary work)
Smoking: never smoker
Alcohol: 1–2 drinks/week; no binge drinking reported
Activity level: walks 20–30 minutes, 3–4 times/week

🧬 Family history

Father: ischemic heart disease (diagnosed in 60s)
Mother: type 2 diabetes
No first-degree relatives with early-onset cancer reported

Contextual notes

No major psychosocial stressors documented in the latest notes. Consider screening for sleep quality, stress/anxiety, diet, and caregiver responsibilities if fatigue persists.

Drug Allergies

🧪 Recorded allergies

Amoxicillin/penicillin — rash (non-anaphylactic)
Ibuprofen/NSAIDs — gastritis/abdominal pain (intolerance)

Clinical notes

Verify allergy details (reaction type, timing, severity, treatment required). If beta‑lactams are needed and history is unclear, consider supervised test dosing or allergy referral.

Safer alternatives (examples)

If true penicillin allergy: consider non–beta-lactam options depending on indication
For pain/fever if NSAID intolerance: consider acetaminophen/paracetamol if appropriate

Red Flags

🚩 Potential red flags to verify

Rapid symptom progression or new severe pain
Unintentional weight loss, night sweats, persistent fever
New neurological deficits, syncope, severe headache
Shortness of breath at rest, hemoptysis, chest pain

From available documents

No explicit emergent red flags documented in the latest notes
One abnormal lab marker noted — correlate clinically and repeat if indicated

Recommendation

Confirm red flags through history/exam. If any are present, escalate the care pathway and consider urgent investigations (e.g., ECG, chest imaging, neuro assessment, or ED referral as appropriate).

Drug Interactions

Potential contraindications / cautions

NSAIDs: avoid or use caution given prior intolerance (gastritis) and potential renal/BP effects with hypertension/diabetes
Macrolide antibiotics (e.g., clarithromycin): can increase statin levels; prefer alternatives or hold statin if clinically indicated
Metformin: review renal function; pause if dehydrated/acute illness or if contrast imaging planned
QT-prolonging combinations: review if adding antiemetics/antibiotics/antipsychotics

Action

Cross-check these cautions against the active medication list and the most recent renal/liver function results. If prescribing something new, run an interaction check and document rationale (especially for antibiotics and pain control).

Generate SOAP

🗣️ S — Subjective

Reports intermittent fatigue and mild headaches. Denies chest pain, shortness of breath, or new focal neurological symptoms.

🩺 O — Objective

Vitals: afebrile in clinic; hemodynamically stable (per note)
Exam: no acute distress; cardiopulmonary exam unremarkable (per documentation)
Investigations: CBC/chemistry panel reviewed; imaging report reviewed (no urgent findings flagged)

🧠 A — Assessment

Improving symptoms; monitor course
Abnormal labs: correlate clinically; consider repeat testing

✅ P — Plan

Continue current management
Follow-up in 2–4 weeks
Return precautions discussed

Referral Letter

To

Specialist / Clinic: Neurology Clinic (Headache Service)

Address: National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433

Re: Kelly Doe

I am referring Kelly Doe for further evaluation of persistent, intermittent headaches with associated fatigue, and to advise on further workup and management.

📝 Clinical summary

Presenting issues: intermittent headaches and fatigue for ~2–3 weeks; no red-flag neurological symptoms documented
Relevant history: hypertension, type 2 diabetes, hyperlipidemia; medication list as above
Key investigations: labs/imaging attached
Treatments to date: conservative measures; paracetamol PRN with partial relief

Reason for referral

Please assess for secondary headache causes and advise on an evidence-based management plan. If additional investigations (e.g., targeted imaging, fundoscopy/visual assessment, or lab workup) are required, kindly recommend.

Sincerely

Dr Rae Lim

Primary Care

CareHero AI (Mockup)

Tel: +65 6XXX XXXX

Schemes & Subsidies

🇸🇬 Potential Singapore (MOH-related) schemes to consider

CHAS: subsidies for common outpatient conditions at CHAS clinics (tier depends on household income and citizenship/PR status)
MediSave: outpatient chronic disease management under CDMP for eligible conditions; also claimable for selected day surgeries/procedures
MediShield Life: national basic health insurance—primarily for inpatient claims (subject to conditions and limits)
Pioneer / Merdeka Generation: additional subsidies for eligible older Singaporeans (age/criteria dependent)

What I would check next

Eligibility: citizenship/PR status, household income, and CHAS tier (if any)
Care setting: polyclinic vs CHAS GP vs specialist outpatient clinic
Service type: chronic disease follow-up (CDMP) vs acute visit
Financing: MediSave claimability and whether MediShield Life is relevant

Notes

This is a practical shortlist rather than an exhaustive benefits check. Confirm the latest eligibility rules on MOH/CPF guidance and involve a medical social worker/financial counsellor for definitive advice and documentation requirements.

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Kelly Doe

Today

Consultation case note

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

(Preview text intentionally short.)

Note

14/01/2026

Chest X-ray (image)

Image

Follow-up note

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

(Preview text intentionally short.)

Note

13/01/2026

Medication reconciliation note

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

(Preview text intentionally short.)

Note

Vitals check-in

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

(Preview text intentionally short.)

Note

12/01/2026

Telephone triage note

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

(Preview text intentionally short.)

Note

09/01/2026

Specialist referral letter (PDF)

PDF

06/01/2026

Discharge summary note

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

(Preview text intentionally short.)

Note

01/01/2026

Care plan update

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

(Preview text intentionally short.)

Note

25/12/2025

Initial intake note

Subjective: ...
Objective: ...
Assessment: ...
Plan: ...

(Preview text intentionally short.)

Note

Recent Visits Summary

🧾 Visit overview

Kelly Doe attended for follow-up review. Symptoms are improving overall with intermittent fatigue and mild headaches.

🔎 Key findings

Vitals stable; no acute distress reported
Lab trend: mild abnormalities noted; recommend recheck as planned
Imaging: no urgent findings flagged in latest report

🗓️ Plan (next 2–4 weeks)

Continue current management and monitor symptoms
Repeat labs if symptoms worsen or per follow-up schedule
Safety net: seek urgent care for chest pain, persistent fever, worsening shortness of breath, new neuro deficits

Patient Background

🪪 Demographics

Name: Kelly Doe
Gender: Female
DOB: 1987-03-14
NRIC: S8723456D

Summary

Summary compiled from the most recent notes, lab report, and uploaded imaging. This is a working clinical snapshot intended to help you quickly orient; confirm details against source documents.

Past medical history: hypertension; type 2 diabetes mellitus; hyperlipidemia; seasonal allergic rhinitis
Past surgical history: laparoscopic appendectomy (2016)
Current concerns: intermittent fatigue and mild headaches over the last 2–3 weeks; here for follow-up review

💊 Medication list (from notes)

Amlodipine 5 mg PO daily
Metformin XR 500 mg PO nightly with food
Atorvastatin 10 mg PO nightly
Cetirizine 10 mg PO PRN allergies
Paracetamol 1 g PO PRN headache/fever (max 4 g/day)

Social & Family History

🏠 Social history

Living situation: lives with spouse; independent with ADLs
Occupation: office administrator (mostly sedentary work)
Smoking: never smoker
Alcohol: 1–2 drinks/week; no binge drinking reported
Activity level: walks 20–30 minutes, 3–4 times/week

🧬 Family history

Father: ischemic heart disease (diagnosed in 60s)
Mother: type 2 diabetes
No first-degree relatives with early-onset cancer reported

Contextual notes

No major psychosocial stressors documented in the latest notes. Consider screening for sleep quality, stress/anxiety, diet, and caregiver responsibilities if fatigue persists.

Drug Allergies

🧪 Recorded allergies

Amoxicillin/penicillin — rash (non-anaphylactic)
Ibuprofen/NSAIDs — gastritis/abdominal pain (intolerance)

Clinical notes

Verify allergy details (reaction type, timing, severity, treatment required). If beta‑lactams are needed and history is unclear, consider supervised test dosing or allergy referral.

Safer alternatives (examples)

If true penicillin allergy: consider non–beta-lactam options depending on indication
For pain/fever if NSAID intolerance: consider acetaminophen/paracetamol if appropriate

Red Flags

🚩 Potential red flags to verify

Rapid symptom progression or new severe pain
Unintentional weight loss, night sweats, persistent fever
New neurological deficits, syncope, severe headache
Shortness of breath at rest, hemoptysis, chest pain

From available documents

No explicit emergent red flags documented in the latest notes
One abnormal lab marker noted — correlate clinically and repeat if indicated

Recommendation

Confirm red flags through history/exam. If any are present, escalate the care pathway and consider urgent investigations (e.g., ECG, chest imaging, neuro assessment, or ED referral as appropriate).

Drug Interactions

Potential contraindications / cautions

NSAIDs: avoid or use caution given prior intolerance (gastritis) and potential renal/BP effects with hypertension/diabetes
Macrolide antibiotics (e.g., clarithromycin): can increase statin levels; prefer alternatives or hold statin if clinically indicated
Metformin: review renal function; pause if dehydrated/acute illness or if contrast imaging planned
QT-prolonging combinations: review if adding antiemetics/antibiotics/antipsychotics

Action

Generate SOAP

🗣️ S — Subjective

Reports intermittent fatigue and mild headaches. Denies chest pain, shortness of breath, or new focal neurological symptoms.

🩺 O — Objective

Vitals: afebrile in clinic; hemodynamically stable (per note)
Exam: no acute distress; cardiopulmonary exam unremarkable (per documentation)
Investigations: CBC/chemistry panel reviewed; imaging report reviewed (no urgent findings flagged)

🧠 A — Assessment

Improving symptoms; monitor course
Abnormal labs: correlate clinically; consider repeat testing

✅ P — Plan

Continue current management
Follow-up in 2–4 weeks
Return precautions discussed

Referral Letter

To

Specialist / Clinic: Neurology Clinic (Headache Service)

Address: National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433

Re: Kelly Doe

I am referring Kelly Doe for further evaluation of persistent, intermittent headaches with associated fatigue, and to advise on further workup and management.

📝 Clinical summary

Presenting issues: intermittent headaches and fatigue for ~2–3 weeks; no red-flag neurological symptoms documented
Relevant history: hypertension, type 2 diabetes, hyperlipidemia; medication list as above
Key investigations: labs/imaging attached
Treatments to date: conservative measures; paracetamol PRN with partial relief

Reason for referral

Sincerely

Dr Rae Lim

Primary Care

CareHero AI (Mockup)

Tel: +65 6XXX XXXX

Schemes & Subsidies

🇸🇬 Potential Singapore (MOH-related) schemes to consider

CHAS: subsidies for common outpatient conditions at CHAS clinics (tier depends on household income and citizenship/PR status)
MediSave: outpatient chronic disease management under CDMP for eligible conditions; also claimable for selected day surgeries/procedures
MediShield Life: national basic health insurance—primarily for inpatient claims (subject to conditions and limits)
Pioneer / Merdeka Generation: additional subsidies for eligible older Singaporeans (age/criteria dependent)

What I would check next

Eligibility: citizenship/PR status, household income, and CHAS tier (if any)
Care setting: polyclinic vs CHAS GP vs specialist outpatient clinic
Service type: chronic disease follow-up (CDMP) vs acute visit
Financing: MediSave claimability and whether MediShield Life is relevant

Notes

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Kelly Doe

15/01/2026

Consultation case note

Laboratory report (PDF)

14/01/2026

Fundus photograph (image)

Chest X-ray (image)

Follow-up note

13/01/2026

Medication reconciliation note

Vitals check-in

12/01/2026

Telephone triage note

09/01/2026

Specialist referral letter (PDF)

06/01/2026

Discharge summary note

01/01/2026

Care plan update

25/12/2025

Initial intake note

Recent Visits Summary

🧾 Visit overview

🔎 Key findings

🗓️ Plan (next 2–4 weeks)

Patient Background

🪪 Demographics

Summary

💊 Medication list (from notes)

Social & Family History

🏠 Social history

🧬 Family history

Contextual notes

Drug Allergies

🧪 Recorded allergies

Clinical notes

Safer alternatives (examples)

Red Flags

🚩 Potential red flags to verify

From available documents

Recommendation

Drug Interactions

Potential contraindications / cautions

Action

Generate SOAP

🗣️ S — Subjective

🩺 O — Objective

🧠 A — Assessment

✅ P — Plan

Referral Letter

To

Re: Kelly Doe

📝 Clinical summary

Reason for referral

Sincerely

Schemes & Subsidies

🇸🇬 Potential Singapore (MOH-related) schemes to consider

What I would check next

Notes

Connect

CMS & Data Sources

Consultation case note

Case Note Editor

Kelly Doe

Today

Consultation case note

14/01/2026

Chest X-ray (image)

Follow-up note

13/01/2026

Medication reconciliation note

Vitals check-in

12/01/2026

Telephone triage note

09/01/2026

Specialist referral letter (PDF)

06/01/2026

Discharge summary note

01/01/2026

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Artificial Intelligence