The Long Case: examples of summaries "In summary, I have seen a 55-year-old man with a history of typical stable angina, with chest pain that occurs only on exertion. His risk factors include smoking 20 cigarettes per day. Examination was unremarkable apart from hypertension and an ejection systolic murmer. He needs a 12-lead ECG, an exercise ECG, a chest X-ray and electrolytes, as well as cardiac enzymes including troponins to exclude and acute event. Depending on the results, I think he should be started on a beta-blocker, aspirin and a statin". |
| "In summary, I have seen a 60-year-old lady with a history of metastatic breast cancer, who now presents with acute breathlessness. Examination reveals signs consistent with a left-sided pleural effusion. She needs the effusion tapped, and samples sent to Cytology, Microbiology for Gram-staining and to Chemistry to determine if it is a transudate or an exudate. She is likely to need a chest drain, and referral to the oncologists for further management." |
"In summary, I have seen a right-handed 65-year-old man who was admitted with an acute stroke having been found on the floor after a number of days. Examination revealed an upper motor neurone weakness on the left side with left arm and left leg weakness. He also had an upper motor neurone VIIth nerve palsy, with sparing of the upper part of his face. He needs admission to the Stroke Unit, a full blood count and electrolytes, and intravenous fluids as he appears dehydrated." [ Back to The Long Case ] [ Clinical Examinations home page ] |