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Waiting Room Summary
Patient Summary (Mock)
Generated by Certuma AI after digital waiting room intake. Delivered to clinician before consult.
Patient
| Name | María G. |
|---|---|
| Age / Sex | 34 / F |
| Location | Buenos Aires |
| Visit Type | Telehealth (Doc24) |
| Consent | AI-assisted care + recording consented |
Chief Complaint
“Burning when I pee” for 3 days. Urinary frequency and urgency.
No fever. No flank pain. No pregnancy. No vaginal discharge.
Triage & Escalation
| Red Flags | None detected |
|---|---|
| Escalation | Not required |
| Risk Level | Low |
Allergies / Meds
| Allergies | None reported |
|---|---|
| Current Meds | None |
| PMH | No diabetes, no kidney disease |
Differential
| Uncomplicated UTI | 82% |
|---|---|
| Vaginitis | 10% |
| STI (Chlamydia/Gonorrhea) | 5% |
| Pyelonephritis | 2% |
| Interstitial Cystitis | 1% |
Guideline Map
| Primary Guideline | IDSA 2024 UTI |
|---|---|
| Secondary | AUA 2023 |
| MedCanon Status | Concordant |
| Confidence | High (0.94) |
Recommended Plan
Diagnosis: Uncomplicated UTI
Treatment: Nitrofurantoin 100mg BID x 5 days
Follow-up: 7-day symptom check. Return if fever, flank pain, or no improvement in 48 hours.
EHR-Ready SOAP Note (Draft)
S: 34F with 3 days dysuria, frequency, urgency. No fever, flank pain, or vaginal discharge.
O: Telehealth visit. No vitals. No PMH. No meds. No allergies reported.
A: Uncomplicated cystitis (UTI). Differential considered: vaginitis, STI, pyelonephritis.
P: Nitrofurantoin 100mg BID x 5 days. Counsel on hydration, return precautions. Follow-up in 7 days.
AI vs Doctor Diff (Example)
AI Recommendation
Dx: Uncomplicated UTI
Tx: Nitrofurantoin 100mg BID x 5 days
Follow-up: 7-day symptom check
Escalation: None
Doctor Final Plan Dx: Uncomplicated UTI Tx: Nitrofurantoin 100mg BID x 5 days Tx: TMP-SMX 160/800mg BID x 3 days Follow-up: 7-day symptom check Escalation: None