The way in which a doctor might arrive at the example summary below is explained in the Oxford Handbook of Clinical Diagnosis, 3rd edition, pages 25 to 60. The Oxford Handbook of Clinical Diagnosis also gives 550 pages of examples of typical diagnoses, supporting 'evidence' (i.e. obtained from the patient) and outline treatments.
A patient or supporter can write such an evidence-based summary as explained in 'How to write a self-explanatory summary' (click on the underlined words to be taken to this page). A basic summary can be created by adding the dates in blue. The treatments can be added as shown in the green text. The actual symptoms, examination findings, test results, needs and preferences (in brown text) can be added immediately or perhaps later with help of a doctor or nurse. These colours are only used to clarfiy these 'teaching' examples!)
A TYPICAL SELF EXPLANATORY SUMMARY
Acute follicular (bacterial) tonsillitis (causing dehydration)
Outline evidence: Original symptoms on 18/10/15 (Severe sore throat for 2 days, getting worse), examination findings on 18/10/15 (Large red tonsils with linear creamy patches), test results on 18/10/15 (WCC of 18.3 x 109/L with 90% neutrophils), needs and preferences on 18/10/15 (relief of symptoms and explanation of their cause). These are also the latest symptoms, examination findings, test results.
Outline management: Advice: diagnosis not agranulocytois due to carbimazole. Treatments: Paracetamol 500 mg 6 hourly PRN. Begin penicillin V 500mg qds. Next assessment: Ward round next day on 19/10/15.
Dehydration and postural hypotension from infection
Outline evidence: Original symptoms on 18/10/15 (Sudden loss of consciousness after getting up from chair, recovery within a minute), examination findings on 18/10/15 (Fall in BP on standing. See above evidence of acute infection), test results on 18/10/15 (Urea 10.1 mmol/l, Creatinine 110 mmol/l), needs and preferences on 18/10/15 (relief of symptoms).
Outline management: Advice: Admission to hospital. Treatments: Encourage oral fluids. For iv fluids if unable to drink > 1 litre in 12 hours. Next assessment: nurse to review oral intake after 2 hours.
Thyrotoxicosis probably now controlled
Outline evidence: Original symptoms on ?/4/15 (Anxiety and weight loss), examination findings on ?/4/15 (low weight), test results on ?/4/15 (abnormal thyroid function tests), needs and preferences on ?/4/15 (relief of smptoms). Latest symptoms, examination findings, test results on 18/10/15 (no heat or cold intolerance, no tremor or lid lag, reflexes normal).
Outline management: Advice: Thyroid function tests sent on 18/10/15 -awaiting result of T4 and TSH. Treatments: Carbimazole 5 mg once daily since 7/7/15. Next assessment when latest thyroid test available.
Possible type 2 diabetes mellitus
Outline evidence: Original test results on 18/10/15 (Urine glucose ‘+’. No ketones. Random glucose 8.4 mmol/l).
Outline management: Advice: Monitor blood sugar before and 2 hours after meals while in hospital -awaiting result of HbA1c. Treatments: Controlled carbohydrate diet from 18/10 15. Next assessment: when HbA1c result available.
Impaired ability to self-care currently
Outline evidence: Original symptoms on 18/10/15 (Alone in a flat at present. Parents 200 miles away),
Outline management: Advice: Hospital admission until recovered. Next assessment: Ward round next day on 19/10/15.