How to summarise multiple visits:

• Jaime presented on three occasions. Initially, he presented with

tonsillitis; however, three weeks later his condition worsened with
brown urine, tonsillar hypertrophy and lethargy. In addition,
macroscopic haematuria was detected in a urinalysis. Therefore, post-
streptococcal nephritis was suspected and further tests were ordered.
• On today’s review, the tests revealed increased urea, creatinine,
ASOT and……As Jaime’s diagnosis of …..has been confirmed, further
management of his condition would be appreciated.
Not summarised (too long)
• Regarding her medical and family history, Mrs Khaze had a lumpectomy five years ago for a benign
lump found in her right breast; however, her follow-up mammogram two years later was clear. It is
important to note that her sister had breast cancer seven years ago, which you successfully treated
with a mastectomy and axillary clearance.

• On the 22/10/17, Mrs Khaze presented with a complaint of a painless lump in her left breast that
she found six weeks ago. On examination, the lump was non-tender with ill-defined margins.
Although there was an absence of nipple discharge with palpable, mobile, axillary lymph nodes, a
repeat mammogram and an ultrasound were ordered, and Mrs Khaze was asked to come back for a
review in two weeks’ time.

• On review, the ultrasound revealed an 18X16 nodule and her mammogram showed an area that is
highly suspicious of malignancy with multiple nodules at the axilla. Thus, a core biopsy was
performed, treatment options were discussed, and 10 mg of diazepam was prescribed due to the
patient developing anxiety about the possibility of cancer.

• On today’s follow-up visit, Mrs Khaze’s biopsy results revealed… She has requested you as her
surgeon and is interested in the possibility of reconstructive surgery as well.
 Summarised

• Regarding Mrs Khaze’s medical and family history…

• Mrs Khaze presented on two occasions regarding a left breast lump that she had
found six weeks ago. The lump was non-tender with ill-defined margins; therefore,
a repeat mammogram and an ultrasound were ordered. The ultrasound revealed
an 18X16 nodule and her mammogram showed an area that is highly suspicious of
malignancy with multiple nodules at the axilla. Thus, a core biopsy was performed,
treatment options were discussed, and 10 mg of diazepam was prescribed due to
the patient developing anxiety about the possibility of cancer.

• On today’s follow-up visit,…….

 Refusal
A man is requesting the results of his wife’s pregnancy test. He has come alone to the
clinic as his wife is unable to attend due to her work commitments.

Task:

• Enquire about the patient’s wife and why she hasn’t come to the clinic for her pregnancy
results
• Explain that the results are ready, but that legally you cannot discuss the results without
the patient’s attendance.
• Respond to patient’s questions
• Inform him that the only way you can give results is if his wife comes to the clinic or
writes a letter of authorisation.