1、Case Report WritingWriting:Case reportwA case report is a detailed report of the symptoms,signs,diagnosis,treatment and follow-up of one or two individual patients.It usually describe an unusual or novel occurrence.Writing:Case reportwCase reports permit discovery of new diseases and unexpected effe
2、cts(adverse or beneficial)as well as the study of mechanisms,and they play an important role in medical education.Case reports and series have a high sensitivity for detecting novelty and therefore remain one of the cornerstones of medical progress;they provide many new ideas in medicine.(Vandenbrou
3、cke,2001)Writing:Case reportFamous scientific case reportsFamous scientific case reports wThe discovery of AIDS in Los Angeles in 1981wSigmund Freud reported on numerous cases,including Anna O.,Dora,Little Hans,Rat man,and Wolf man wPaul Broca reported on language impairment following left hemispher
4、e lesions in the 1860s wThe discovery of congenital malformation of neonatals caused by ingestion of thalidomide by the mothers of these babiesWriting:Case reportTypes of case reportsTypes of case reports Most case reports are on one of six topics:1)An unexpected association between diseases or symp
5、toms.2)An unexpected event in the course of observing or treating a patient.3)Findings that shed new light on the possible pathogenesis of a disease or an adverse effect.4)Unique or rare features of a disease.5)Unique therapeutic approaches.6)A positional or quantitative variation of the anatomical
6、structures.Writing:Case reportStages in writing a case report wFinding a rare casewLiterature searchwCollecting information related to the case,including consent from the patientwRevising and editingWriting:Case reportwStructure of a case report:wIntroduction wCase PresentationwDiscussion1.Reference
7、s1.IntroductionThe introduction is a brief overview of the larger problemaddressed by the case.The overlying message of the section is,“X is important to understand because”For example:“Small cell carcinoma of the prostate is extremely rare.When it does occur,it is usually in concordance with prosta
8、tic adenocarcinoma Because this condition is rare,no standard treatment regimen has been established”After the problem is described,many authors close the introduction section by describing in one sentence the patient who represents the case.“This case report describes clinical characteristics of a
9、67-year old man with smallcarcinoma of the prostate.”This creates a smooth transition to the next section,The Case.Special Language StructureswDefining an illness/term,or presenting the Defining an illness/term,or presenting the concerned issueconcerned issuewisisSmall cell carcinoma of the prostate
10、 is extremely rare.Acute angle closure glaucoma is a great mimic of the other ocular,neurological and gastrointestinal condition.2.is,but/however.is,but/however Nasal bleeding is a common illness,but simple analysis indicates that patients with hematopathy who also suffer nasal bleeding accounts for
11、 5.1%of total nasal bleeding cases.Special Language StructureswPresenting the case(s)with peculiaritiesPresenting the case(s)with peculiarities 1.we report/present one patient withwe report/present one patient with We report one case of We report one case of we present two children patients with gon
12、orrhea who were misdiagnosed as other diseases.2.is not fully understood/remains controversialis not fully understood/remains controversial The pathogenic mechanism of aplastic disease is not fully understood.The mechanism of angle closure glaucoma remains controversial.2.The caseAs in a case presen
13、tation,first describe the person,then provide a history of the presenting condition.Next,reveal the results of the physical exam and relevant tests,and describe the treatment.Finally,describe the expected outcome of the treatment plan and contrast it to the actual outcome,when something unusual occu
14、rs.2.The case(cont)wDescription of the patientwHistory of presenting conditionwPhysical exam and testswDiagnosis&treatmentwActual outcome1.A woman/man agedwas admitted with/for A(age)patient withwas seen/admitted/presented oneself/came to Late one afternoon,a 31-year-old grocery delivery driver pres
15、ented himself to the emergency department complaining of left-sided chest pain.2.The patient complained of/described The patient complained of some difficulty urinating,but urine output was quite good.wHistory:Present since morning,the patients pain radiated to his left jaw and down his left arm.The
16、 pain increased with deep respiration or strenuous activity.He was sweaty and dizzy.He complained of a cough with bloody sputum.This patient did a lot of heavy lifting,up to 100 pounds at a time.He first noted pain when getting into his truck after a delivery.1.were/appeared/showed/revealed(ab)norma
17、l/,1.were/appeared/showed/revealed(ab)normal/,(but)(but)The right renal artery and branch arteries appeared normal without evidence of occlusion or stenosis from intrinsic vascular disease.2.No abnormality was found on2.No abnormality was found on3.displayed/showed/revealed 3.displayed/showed/reveal
18、ed 4.was/were(not)detected/noted.4.was/were(not)detected/noted.About one week prior to this admission,a chest X-ray demonstrated that more fluid presented than before was noted.1.was diagnosed as having/suffering1.was diagnosed as having/suffering was given the diagnosis of was given the diagnosis o
19、f At that time,he was diagnosed as having diabetes mellitus and hypertension.2.The patient was begun/started on (medicine or 2.The patient was begun/started on (medicine or procedure)procedure)For this reason,he was begun on digitalis and fluid restrictions were instituted.3.was performed/given/adop
20、ted3.was performed/given/adopted was subjected to was subjected to (a treatment/operation,etc.)(a treatment/operation,etc.)On April 30,a right and left heart catheterization from a right axillary vein cutdown was performed.wActual outcome:The pain recurred,the patient went to the ER then the ICU,the
21、 cardiac tests were normal.Then thoracic radiographs and MRI were done,revealing disk bulges in the neck.An orthopedic surgeon performed an arthroscopic,micro-discectomy at the C6-7 level,on the left.The pain resolved.3.Discussion The discussion is the most important section!In this section,the auth
22、or may first review the literature,and then discusses how the existing literature relates to the individual case.Was there a mismatch in what is known about the condition and its particular presentation in this case?If this is a story about surprise or puzzlement,the revelation process can be descri
23、bed here.If existing hypotheses about the condition did not fit the case,the author might propose a new hypothesis.Conclusion is not always necessary in a case report but if it is,summaries the message in a few sentences.1.In conclusion/To sum up/Therefore 1.In conclusion/To sum up/Therefore In conc
24、lusion,liver function should be assessed in any patient with unexplained acute pains in liver area.2.One lesson of this case is 2.One lesson of this case is One lesson of this case is the need for a detailed history before intervention.3.may give rise to 3.may give rise to Pressure effects may give
25、rise to jaundice,cholangitis,acute and recurrent pancreatitis and rarely duodenal obstruction.4.ReferencesThe reference section is boring and time consuming but extremely important.Keep to the style that your journal requires.Additional Reading MaterialsAdditional Reading Materials Read the followin
26、g case reports as the additional Read the following case reports as the additional reading materials.reading materials.wA 39-Year-Old Man with Chest Pain,Arthralgias,A 39-Year-Old Man with Chest Pain,Arthralgias,and a Mediastinal Massand a Mediastinal MasswCase Report:Paraarticular Soft-Tissue Osteoma of Case Report:Paraarticular Soft-Tissue Osteoma of the Hip the Hip wInfitrating Myoepithelial Carcinoma of the Breast,a Infitrating Myoepithelial Carcinoma of the Breast,a case report and cytologic-histologic Correlationcase report and cytologic-histologic Correlation
