Summary and diagnosis

Structure

The summary must draw on all areas in the earlier parts of the report. New information cannot be introduced.

Essentially the summary will contain a brief outline of:

  • who the patient is
  • what their problems are
  • what effects the problems are having on the patient.

It also needs to include a brief indication of:

  • why the problems arose (precipitating factors)
  • how the problems arose (predisposing factors)
  • factors influencing progression / the course of the problems (perpetuating and protective factors).

Features may be drawn from all aspects of the history and examination, and should include relevant negatives (features of the diagnosis and differential diagnoses that are not present).

The diagnosis will require you to synthesise signs and symptoms in the case report to identify core problems. You should explicate your reasoning for drawing the links between signs and symptoms and diagnostic decision-making. In other words, what important aspects in the History, Mental State Examination and Physical Examination lead you to making the provisional diagnosis? Pick out the relevant pieces of these sections and make links with the final diagnosis (and differential diagnoses).

One way to approach explaining your reasoning is for you to take each differential diagnosis and write down the pros and cons evident in the earlier parts of your report that serve to support or discount the likelihood of the differential diagnosis.

Writing summary and diagnosis

Links are made between symptoms and pathophysiological processes, which help explicate the reasoning for arriving at a diagnosis:

Lucy has also experienced symptoms of increased intracranial pressure, such as nausea, vomiting, and mild photophobia. Hence, it is likely that the tumour is a space-occupying lesion, which is exerting the oedema effect and causing the symptoms that Lucy is experiencing.

The evidence supporting the diagnosis is provided from information gleaned earlier in the report.

  • Diagnosis: The tumour is a space-occupying lesion
  • Supporting evidence: Lucy's symptoms of increased intracranial pressure (nausea, vomiting, mild photophobia).

Connections between the conclusions reached (diagnosis) and the supporting evidence (signs and symptoms) are made with illatives, or argument indicators. There are two kinds of argument indicators. Either conclusion indicators or premise indicators may be used in your text to link the evidence that supports the diagnosis.

Conclusion indicators:

Conclusion indicators are used to introduce a diagnosis after the evidence has been stated. Some conclusion indicators are:

  • therefore
  • so
  • hence
  • thus
  • accordingly
  • and (so).

Example:

Lucy has also experienced symptoms of increased intracranial pressure, such as nausea, vomiting, and mild photophobia. Hence, it is likely that the tumour is a space-occupying lesion.

Premise indicators:

Premise indicators are used to introduce the evidence that supports a diagnosis. Some premise indicators are:

  • because
  • since
  • for
  • given that
  • for the reason that
  • granted that.

Example:

It is likely that the tumour is a space-occupying lesion because Lucy has experienced symptoms of increased intracranial pressure, such as nausea, vomiting and photophobia.

Example:

Given that Lucy's father died 15 years ago of stroke related causes, her mother and her sister both have cardiovascular illness, and Lucy has HERNS syndrome, there is a high probability that the tumour has a vascular cause.