Clinical  Impression

Where are we going?

There comes a point in any patient evaluation when a physician must formulate his or her own opinion on the patient’s status. The quality of this opinion is obviously determined by the amount of training and experience of the doctor. The clinical impression – a “state of the patient” declaration is a useful way of assessing the problems presented to you prior to your assessment, the new problems that you discovered, and whether these are resolving or not.

“My impression of the problems: 1) The acute lung injury is not resolving, we are unable to wean, but do have a treatable cause – the nosocomial pneumonia. 3) The patient’s heart rate remains too high, beta blockade is inadequate. In addition, the patient should be reviewed for possible percutaneous coronary intervention (PCI). The patient’s renal status is gradually improving, although polyuria is causing some difficulties with electrolytes, which require supplementation. 3) The hyperbilirubinemia remains unexplained – it may be caused by hemolysis, the patient did have a massive transfusion, but may also be due to sepsis or cholestasis. I do not believe that we should be overly concerned about this problem at this time. 4) The wound site is granulating nicely 5) The pressure sore is of some concern. The patient had this on admission, he came from a nursing home, we have obtained an air bed, but the ulcer, if anything, is getting worse.”

Copyright Patrick Neligan 2001-2002

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