Spice-up “Impression” and/or Diagnosis

The Emergency Department is the place where most diagnoses are made.

Quite frequently, patients in the Emergency Department will be admitted without a firm diagnosis. Not being able to give an exact diagnosis is not in itself a failure of management. It is a matter of simply describing the patient’s current illnesses

I’ve always emphasized to myself and other medical officers to clearly state their diagnosis/impression. Lets face it, how often do you think doctors in the ward will read the whole documentation once patients have been admitted? Most of time they will just read our Impression: e.g., Acute Inferior MI.

By not reading the whole document, the team upstairs will not know some of the important things (why the diagnosis was made, findings, management and etc.) that happened in the Emergency Department.

Therefore during their morning rounds, the consultants will not be fully informed regarding the initial management and will assume most of the patients’ management has been done by their team rather than otherwise.

Once, I encountered a cardiologist that did not realize most patients with AMI in his center received their thrombolytic agent in the ED (without the presence of the cardiology team). In fact, patients’ complications will be fully managed in the ED as needed (central venous line, arterial line, inotropes, temporary pacemaker, etc.) and yet it is presumed that these things were done by the cardiology team.

So my suggestion is simple, we spice up the only thing that we are sure the receiving team will read, i.e., The Impression.

Here are some of the examples that I have started to write during my rounds.

Suggestion #1:
Imp: Acute Inferior MI

Change to
Imp: Acute Inferior MI with right ventricular involvement complicated by acute pulmonary edema (Killip II), reperfused post-Streptokinase

Suggestion #2:
Imp: Thyphoid

Change to
Imp: Clinical Thyphoid (Awaiting serology) in view of
1) Relative bradycardia
2) Constipation preceeding diarrhea

Suggestion #3:
Imp: Septic shock secondary to pneumonia

Change to
Imp:
1) Septic shock secondary to pneumonia (currently on single inotrope, SvO2 improving)
2) Intubated for respiratory distress with difficult airway (Comark Lehand III)

Suggestion #4:
Imp: AGE with severe dehydration

Change to
Imp:
1) AGE with severe dehydration - failed outpatient therapy
2) Hypokalemia secondary to 1 (K correction started)
3) Lactic acidosis secondary to 1 (improved after initial fluid bolus)

Suggestion #5:
Imp: MVA with left femur fracture

Change to
Imp:
1) Alleged MVA with close fracture of left femur
2) Complicated by Class II shock (Improve with fluid bolus and traction)