Patient ID: CESJUJM2606016
Name: Sam Sam
Age: 27 years
Gender: Female
Category: Adult (20–64 yrs)
Care module
This visit
Maternal & Reproductive Health
Step 8
Summary of Care
CESJUJM2606016
Sam Sam
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Clinical Summary of Care
Visit #17 — June 11, 2026 at 12:02 PM
Module: Maternal & Reproductive Health
1. Patient Demographics
2. Consultation
Presenting Complaint(s): Abnormal urination (frequency / nocturia / oliguria)
Maternity module
Menstrual: menarche —; cycle — d; regular —; flow — d; amount —; dysmenorrhea —; LNMP —
Obstetric summary: G— P—; term —; preterm —; abortions —; living —
Past pregnancies:
- Year —; GA —; —; Apgar —; complications —; outcome —; BW —; sex —
Antenatal Care: ANC visit 1
Postnatal: mode —; —; breastfeeding —; recovery —
Sexual history: active —; partners —; new partner —; dyspareunia —; libido —
Contraception: current —; past —; compliance —; side effects —; future fertility —
Recorded by: Not specified
3. Physical Examination
No physical exam findings recorded.
Recorded by: Not specified
5. Definitive Diagnosis (ICD-11)
No definitive diagnosis recorded.
Recorded by: Not specified
6. Treatment Plan
Health messages given: No
No management plan recorded.
Recorded by: Not specified
Clinical Summary of Care — Visit #17 — CESJUJM2606016
Generated on August 9, 2026 at 12:07 AM
Path of care: steps and decisions from triage to summary.
flowchart TD
S1["Step 1: Triage
Recorded: Vitals recorded
• Demographics: ID, name, age, gender
• Vital signs: Pulse, BP, RR, Temp; mental compromise / altered acuity t…
• Anthropometrics: Height, weight, MUAC, chest÷abdomen ratio ( 1)"] S2["Step 2: Consultation
Recorded: Abnormal urination (frequency / nocturia / oliguria)
• Presenting symptoms: multi-select with exploration per symptom; free t…
• Drug history: current meds; allergy (what, duration, why)
• Past medical: existing/chronic illness, admissions, procedures, vaccin…
• Family history: familial illnesses
• Personal/social: smoking, alcohol, HIV status, social support, occupat…"] S3["Step 3: Physical Examination
Recorded: Findings recorded
• General examination
• System-specific exam (e.g. neurological, digestive)
• Maternity module (if applicable): breast; obstetric abdomen; pelvic (d…
• Consolidate exam findings"] S4["Step 4: Differential Diagnosis
Recorded: No differential recorded
• Select provisional diagnoses from ICD-11 dropdown"] S5["Step 5: Diagnostics
Recorded: No orders
• Lab tests: blood (CBC, Hb, coagulation), biochemistry (renal, liver, e…
• Radiology: X-ray, US, CT, MRI
• Consolidate lab and imaging findings"] S6["Step 6: Definitive Diagnosis
Recorded: No definitive diagnosis
• Select definitive diagnosis from ICD-11 dropdown"] S7["Step 7: Management
Recorded: Plan recorded
• Care pathway after management: pharmacy, inpatient, or theatre (before…
• Final disposition: follow-up, referral, or mortuary
• Drug management: treatment plan (STG/EML), medications, notes
• Health education messages provided to patient or carer"] S8["Step 8: Summary of Care
Recorded: Care completed
• Comprehensive clinical summary of care (printable)"] S1 --> S2 S2 --> S3 S3 --> S4 S4 --> S5 S5 --> S6 S6 --> S7 S7 --> S8
Recorded: Vitals recorded
• Demographics: ID, name, age, gender
• Vital signs: Pulse, BP, RR, Temp; mental compromise / altered acuity t…
• Anthropometrics: Height, weight, MUAC, chest÷abdomen ratio ( 1)"] S2["Step 2: Consultation
Recorded: Abnormal urination (frequency / nocturia / oliguria)
• Presenting symptoms: multi-select with exploration per symptom; free t…
• Drug history: current meds; allergy (what, duration, why)
• Past medical: existing/chronic illness, admissions, procedures, vaccin…
• Family history: familial illnesses
• Personal/social: smoking, alcohol, HIV status, social support, occupat…"] S3["Step 3: Physical Examination
Recorded: Findings recorded
• General examination
• System-specific exam (e.g. neurological, digestive)
• Maternity module (if applicable): breast; obstetric abdomen; pelvic (d…
• Consolidate exam findings"] S4["Step 4: Differential Diagnosis
Recorded: No differential recorded
• Select provisional diagnoses from ICD-11 dropdown"] S5["Step 5: Diagnostics
Recorded: No orders
• Lab tests: blood (CBC, Hb, coagulation), biochemistry (renal, liver, e…
• Radiology: X-ray, US, CT, MRI
• Consolidate lab and imaging findings"] S6["Step 6: Definitive Diagnosis
Recorded: No definitive diagnosis
• Select definitive diagnosis from ICD-11 dropdown"] S7["Step 7: Management
Recorded: Plan recorded
• Care pathway after management: pharmacy, inpatient, or theatre (before…
• Final disposition: follow-up, referral, or mortuary
• Drug management: treatment plan (STG/EML), medications, notes
• Health education messages provided to patient or carer"] S8["Step 8: Summary of Care
Recorded: Care completed
• Comprehensive clinical summary of care (printable)"] S1 --> S2 S2 --> S3 S3 --> S4 S4 --> S5 S5 --> S6 S6 --> S7 S7 --> S8