Structured reporting: a fusion reactor hungry for fuel

摘要

Analysis of a serum sample, and whole blood on citrate and EDTA. We compare the results to those of December 20th. We observe a slight rise in blood glucose level, but the value is still within normal limits. Erythrocytes sedimentate at a rather fair rate of 25 millimetres per hour, which can be considered just mildly abnormal, taking into account the patient’s gender and age. We notice serum creatinine is 140 micromoles per litre, which corresponds, according to Cockroft-Gault, to a creatinine clearance of 67 millilitres per minute. The other chemical constituents and haematological evaluations are unremarkable, except for a rise in the number of neutrophils, which has tripled in comparison with the last examination.\ud\udImpression\ud\udBiochemically, we see little evolution in this slightly overweight, middle-aged patient with a history of arterial hypertension, but there is a possible suspicion of an acute infection. These results need to be correlated to the clinical presentation.\udDoes this report look familiar? It is unlikely that you have ever received a similar one from your clinical biochemist. Results of biochemical and haematological tests are nearly always presented in a neat, tabular format, with some space for results that cannot be quantified, and for expert comment. In addition, many hospital information systems allow referring clinicians to represent consecutive results graphically, which can help to improve insight into the course of the disease.