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Care module This visit Emergency / Casualty
Step 8

Summary of Care

CESJUJM2606012

vvfs rtyu

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Clinical Summary of Care

Visit #12 — June 11, 2026 at 10:51 AM

Module: Emergency / Casualty

1. Patient Demographics

Patient ID: CESJUJM2606012

Name: vvfs rtyu

Age: 34 years

Gender: Female

Category: Adult (20–64 yrs)

2. Consultation

Presenting Complaint(s): Fever; Other: headache

Other symptoms (free text):

headache

Personal & Social: Smoking Yes (1 packet per day) | Alcohol Yes (five bottles) | Drugs Yes | HIV status/exposure no | Social support No | Occupation —

Recorded by: Not specified

3. Physical Examination

Respiratory

  • Palpation: Abnormal
    • Chest expansion reduced (one area or all over)
    • Chest expansion uneven left vs right
    • Windpipe shifted toward the problem side
    • Windpipe pushed away from the problem side
    • Vibration stronger when patient speaks (possible pneumonia)
    • Vibration weaker (fluid, collapsed lung, or blockage in airway)
    • Chest wall tender — possible broken rib
    • Chest wall tender — possible infection of lung lining
    • Crackling feeling under the skin (air leak)
  • Inspection: Abnormal
    • Working hard to breathe / visibly breathless
    • Breathing too fast or too slow
    • Neck or shoulder muscles helping with breathing
    • Nostrils flaring when breathing in
    • Pursed-lip breathing (often with COPD)
    • Barrel-shaped chest (often with COPD)
    • Sunken chest wall (pectus excavatum)
    • Pigeon chest (pectus carinatum)
    • Spine curve affecting breathing
    • One side of the chest moves less than the other
    • Blue lips or tongue
    • Blue hands or feet
    • Clubbed fingertips (often long-standing lung disease)
    • Chest scars from surgery or drains
    • Obvious neck or chest veins (may suggest blockage)
    • Chest movement reduced on one or both sides
    • Odd chest movement after injury (e.g. rib fracture)
    • Other
  • Percussion: Abnormal
    • Dull sound when tapped (fluid, consolidation, or collapse)
    • Very dull sound (often large fluid around lung)
    • Extra hollow sound (collapsed lung or emphysema)
    • Drum-like sound when tapped (unusual; large air leak)
  • Auscultation: —

Recorded by: Not specified

5. Definitive Diagnosis (ICD-11)
1F40-1F49 Malaria
CA40 Lower Respiratory Infections-Pneumonia
BD1Z Heart failure, unspecified
1B10-1B1Z TB
CA22 Chronic obstructive pulmonary disease

Recorded by: Not specified

6. Treatment Plan

Health messages given: No

No management plan recorded.

Recorded by: Not specified

Clinical Summary of Care — Visit #12 — CESJUJM2606012

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: Fever; Other: headache
• 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: 1F40-1F49, CA40, CA23
• 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: 1F40-1F49, CA40, BD1Z
• 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