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How to write a summary


Use this structure to organise information for writing your summary


Background

Presentation

Physical examination

Investigations

Diagnosis

Treatment

Response to treatment


Advice on discharge




An example is shown below:

Background
Elderly man with COPD and HPT and BPH
Presentation
SOB, nasal discharge, cough with sputum
Physical examination
BP 167/100mm Hg, RR 24/min. generalised rhonchi in lungs.
Investigations
x-ray chest hyperinflated lungs;
Diagnosis
AECOPD. URTI
Treatment
Prednisolone, Bisolvon, AVN by nebuliser, Oxygen
Response to treatment

Recovered well
Advice on discharge
Inhaler technique; Accuhaler Seretide changed to Ombrez Breezhaler;  Vaccinations advised.