Patient ID: CESJUJM2606020
Name: Sam Sam
Age: 2 months
Gender: Male
Category: Infant (<1 yr)
Care module
This visit
General OPD
Step 8
Summary of Care
CESJUJM2606020
Sam Sam
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Clinical Summary of Care
Visit #21 — July 10, 2026 at 11:56 AM
Module: General OPD
1. Patient Demographics
2. Consultation
Presenting Complaint(s): Cough
Personal & Social: Smoking No | Alcohol No | Drugs No | HIV status/exposure no | Social support No | Occupation —
Recorded by: Not specified
3. Physical Examination
No physical exam findings recorded.
Recorded by: Not specified
5. Definitive Diagnosis (ICD-11)
1B10-1B1Z
Tuberculosis
1B10-1B1Z
TB
Recorded by: Not specified
6. Treatment Plan
Health messages given: No
No management plan recorded.
Recorded by: Not specified
Clinical Summary of Care — Visit #21 — CESJUJM2606020
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: Cough
• 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: CA07.0, 1B10-1B1Z, CA40
• Select provisional diagnoses from ICD-11 dropdown"] S5["Step 5: Diagnostics
Recorded: 6 order(s)
• 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: 1B10-1B1Z, 1B10-1B1Z
• 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: Cough
• 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: CA07.0, 1B10-1B1Z, CA40
• Select provisional diagnoses from ICD-11 dropdown"] S5["Step 5: Diagnostics
Recorded: 6 order(s)
• 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: 1B10-1B1Z, 1B10-1B1Z
• 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