example of a diagnostic impression

Daniel Parker

2 min read

·

18-03-2025

1

0

Share

Understanding Diagnostic Impressions: Examples and Explanation

Diagnostic impressions are concise summaries of a patient's condition based on the information gathered during a medical evaluation. They represent the clinician's best judgment regarding the nature of the patient's problem. This article will provide examples of diagnostic impressions across various medical specialties and explain their importance. Understanding how diagnostic impressions are formulated is crucial for both healthcare professionals and patients.

What Makes a Good Diagnostic Impression?

A well-written diagnostic impression is:

• Clear and Concise: It avoids jargon and uses easily understandable language.
• Specific: It identifies the specific condition or problem.
• Supported by Evidence: It's based on the patient's history, physical examination findings, and any relevant tests.
• Prioritized: If multiple issues are present, they are listed in order of importance.
• Actionable: It guides further investigation or treatment.

Examples of Diagnostic Impressions Across Specialties

Here are some examples, illustrating the variety of ways diagnostic impressions are presented:

1. Primary Care:

• Example 1: "Acute bronchitis, likely viral in origin. Patient responding well to symptomatic treatment." This is straightforward and indicates the likely cause and response to treatment.
• Example 2: "Hypertension, poorly controlled. Requires further lifestyle modifications and medication review." This highlights an ongoing condition requiring management.
• Example 3: "Suspected urinary tract infection (UTI). Urinalysis pending." This shows a suspected diagnosis pending further investigation.

2. Cardiology:

• Example 1: "Stable angina pectoris. Coronary artery disease likely. Recommend cardiac catheterization." This diagnoses a heart condition and suggests further investigation.
• Example 2: "Atrial fibrillation with rapid ventricular response. Patient currently asymptomatic." This details a specific arrhythmia and its current status.

3. Psychiatry:

• Example 1: "Major depressive disorder, moderate severity. Patient currently exhibiting suicidal ideation requiring close monitoring." This illustrates a serious mental health diagnosis and the need for close supervision.
• Example 2: "Generalized anxiety disorder. Recommend psychotherapy and pharmacotherapy." This outlines a diagnosis and suggested treatment approaches.

4. Dermatology:

• Example 1: "Atopic dermatitis, moderately severe. Prescribe topical corticosteroids." This diagnoses a skin condition and recommends treatment.
• Example 2: "Actinic keratosis, multiple lesions. Recommend liquid nitrogen cryotherapy or excision." This diagnoses precancerous skin lesions and treatment options.

5. Pediatrics:

• Example 1: "Acute otitis media, right ear. Prescribe amoxicillin." This specifies the location of an ear infection and recommends antibiotics.
• Example 2: "Febrile seizure, likely related to viral infection. Close observation recommended." This describes a seizure event and its likely cause.

Importance of Diagnostic Impressions

Diagnostic impressions are vital for several reasons:

• Communication: They facilitate clear communication between healthcare professionals.
• Treatment Planning: They guide the development of a treatment plan.
• Legal Documentation: They form a crucial part of a patient's medical record.
• Patient Understanding: When explained clearly, they help patients understand their condition.
• Referral: They support the process of referring patients to specialists.

How to Improve Diagnostic Impression Writing

For clinicians, focusing on accuracy, clarity, and completeness is key. Using standardized terminology and avoiding ambiguity minimizes confusion. Regularly reviewing and updating diagnostic impressions as new information becomes available is essential for optimal patient care. For patients, asking clarifying questions about the diagnostic impression helps ensure understanding and facilitates shared decision-making in treatment.

This article provides examples to illustrate the varied ways diagnostic impressions are formulated and highlights the importance of clear communication in healthcare. Remember to always consult with your healthcare provider for any health concerns.