4. 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

As well as 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.

Example

Student's report

Lucy is a 34-year old single mother who has recently been diagnosed with a cranial tumour in the right frontal lobe. The diagnosis explains her symptoms of persistent and worsening headache over the last four weeks, which have led her to resign from work and rely more on her mother for support and care. 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. Taking her age and sex into consideration, the lesion is most likely to be a primary lesion, single and benign in nature. In addition, 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.

Lucy has become depressed and withdrawn since finding out that she has a brain tumour. In particular, she is very anxious about the possibility that the biopsy results will show that the tumour is cancerous. Although symptoms of depression and anxiety are not uncommon in patients threatened by a diagnosis of cancer, Lucy has a history of feeling melancholy and, significantly, developed postnatal depression following the birth of her son five years ago. Lucy's response to her current illness needs to be understood in this context, as it will help to assess how well she will cope with the forthcoming diagnosis and future management of her illness.

Upon the mental state examination, Lucy exhibited sullen appearance and limited facial expression. Although articulate, she spoke slowly and softly throughout the interview. Clearly, Lucy has a depressed affect. Her history of childhood depression in conjunction with her recent history of poor appetite, sleep disturbance, energy loss, reduced concentration and feelings of guilt indicate that Lucy is prone to developing a major depressive disorder in response to her current medical condition.

From the information gathered in the history and examination, the following differential diagnosis can be posited:

1) Major depressive disorder
Lucy's unhappy childhood and psychiatric history of depression support this diagnosis. In addition, she meets at least five of the DMS-IV criteria on mental state examination.

2) Biological disorder
The tumour in Lucy's right frontal fossa might affect functions of the frontal lobe, which control thought and personality. Consequently, Lucy's personality traits may be enhanced by such a biological disturbance, making her more prone to stress and depression.

3) Anxiety
Lucy's sudden confinement in hospital, diminished ability to perform daily activities, and concerns about her family and health, predispose her to experiencing anxiety, a potential trigger of depression.

Writing tips:

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.