Summary and diagnosis
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:
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 are used to introduce a diagnosis after the evidence has been stated. Some conclusion indicators are:
- and (so).
Premise indicators are used to introduce the evidence that supports a diagnosis. Some premise indicators are:
- given that
- for the reason that
- granted that.