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Old 12-31-2011
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Question Use of Summary in CS history taking

Everyone emphasizes the importance of Summary. How many times we have to do that?

In the Sample Closure of FA cases, no summary. It is only a counseling. If we do summary in between History and PE, shall we do it again before counseling? ----

After History, we say: based on the information you provided, you have chest pain, started 2 hours ago...blahblah...

After PE, we say again: based on the information and my observation, you have chest pain, started 2 hours ago...blahblah...; then followed by counseling.

Shall we have to repeat like this?

Suggestions and experience are appreciated!

Thanks.
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Old 12-31-2011
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Default Repeating the same sentence is not good

Summarizing is an effective communication techniques that doctors can use to tell their patients what they've understood from them so far.

Never repeat the same summery to your patient, the SP will think that you are being clumsy, redundant, and unconfident. Use it only once (you can do another summery but never the same summery).

Here's what I suggest;
After the patient tells you the story (HPI), you can summarize to him/her and say, .. OK, now what I understand is that you have chest pain, shortness of breath that started yesterday ....

After you finish the physical examination, you can tell the patient ... based on the information that I collected from your history and from the findings of my physical examination, I think you have pneumonia and we need to confirm that by doing some laboratory tests ....

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Old 03-24-2013
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Thank you StepTaker,
I understand you can give the summary right after taking the history or after the physical exam, correct?
Now, are we supposed to give our findings from the physical to the SP also?
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Old 03-25-2013
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You don't need to give details of physical findings.

Like for example you don't need to tell him that "Mr. Smith, you had rebound tenderness in the right lower quadrant of your abdomen upon deep palpation and this goes with appendicitis" ...

Instead you can say "Mr. Smith, your history and physical findings point me toward the possible diagnosis of appendicitis, I will order urgent labs and imaging and will confirm to you after the results".

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