case report current patient

by Rossie Armstrong 6 min read

How to write a patient case report - OUP Academic

4 hours ago Summary: The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion. The abstract of a patient case report should succinctly include the four … >> Go To The Portal


A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine.

Full Answer

How to write a case study on a patient?

Writing Your Patient Case Study

  1. Work on Your Introduction Select a case. You have to identify your focus and scope for the study. ...
  2. Get to Know the Participants You can have one or multiple case participants. ...
  3. Perform Data Analyses Method Your results will depend on your interpretation of the raw data. ...
  4. Report the Case Study Results

How to write a patient care report?

Patient-Centered Care Report example

  • Attach a reference list to your report. ...
  • Describe the outcomes that were not achieved, the extent to which they fell short of expectations, and any variance across demographic groups.
  • Identify the factors (for example: institutional, community, environmental, resources, communication) that may have contributed to any achievement shortfalls. ...

More items...

How to write a medical case report?

Writing up. Write up the case emphasising the interesting points of the presentation, investigations leading to diagnosis, and management of the disease/pathology. Get input on the case from all members of the team, highlighting their involvement. Also include the prognosis of the patient, if known, as the reader will want to know the outcome.

How to review a case report?

related reports, are provided. SUMMARY: The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.

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What is a patient case presentation?

A patient case presentation is a demonstration of a learner's knowledge and skills related to the management of disease states and drug therapies through application to an actual patient case. Typical Information Included in a Patient Case Presentation. 1.

How many patients are in a case report?

Subjects in case series and case report Many publishers strongly stick to the count of the patients reported in the study. After the study reports, [1] suggested that a case report contain patients of less than five individuals, whereas a case series can contain four and more patients.

What does a case report include?

A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine.

How do you write a patient case report?

III. Patient case presentationDescribe the case in a narrative form.Provide patient demographics (age, sex, height, weight, race, occupation).Avoid patient identifiers (date of birth, initials).Describe the patient's complaint.List the patient's present illness.List the patient's medical history.More items...•

How do you take a case history of a patient?

Procedure StepsIntroduce yourself, identify your patient and gain consent to speak with them. ... Step 02 - Presenting Complaint (PC) ... Step 03 - History of Presenting Complaint (HPC) ... Step 04 - Past Medical History (PMH) ... Step 05 - Drug History (DH) ... Step 06 - Family History (FH) ... Step 07 - Social History (SH)More items...

What means case report?

Listen to pronunciation. (kays reh-PORT) A detailed report of the diagnosis, treatment, and follow-up of an individual patient. Case reports also contain some demographic information about the patient (for example, age, gender, ethnic origin).

What makes a good case report?

Case reports should encompass the following five sections: an abstract, an introduction with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, and a brief summary of the case and a conclusion.

When do we use case report?

Case reports often describe:Unique cases that cannot be explained by known diseases or syndromes.Cases that show an important variation of a disease or condition.Cases that show unexpected events that may yield new or useful information.Cases in which one patient has two or more unexpected diseases or disorders.

How do you write a good patient care report?

There are seven elements (at a minimum) that we have identified as essential components to documenting a well written and complete narrative.Dispatch & Response Summary. ... Scene Summary. ... HPI/Physical Exam. ... Interventions. ... Status Change. ... Safety Summary. ... Disposition.

How do I write a report?

How to write a report in 7 steps1 Choose a topic based on the assignment. Before you start writing, you need to pick the topic of your report. ... 2 Conduct research. ... 3 Write a thesis statement. ... 4 Prepare an outline. ... 5 Write a rough draft. ... 6 Revise and edit your report. ... 7 Proofread and check for mistakes.

How do you present a case?

Top tipsRemember the purpose of the presentation.Be flexible; the context should dictate the content of the presentation.Always include a presenting complaint.Present your findings in a way that shows understanding.Have a system.Use appropriate terminology.

What is required to submit a case report?

Journals often have specific requirements for publishing case reports, which could include a requirement for informed consent, a letter or statement from the IRB and other things.

What should I do after writing a case report?

Once you have written a draft of the case report, you should seek feedback on your writing, from experts in the field if possible, or from those who have written case reports before .

Why is it important to write a case report?

the reason you would go to the trouble of writing one, is that the case is sufficiently unique, rare or interesting such that other medical professionals will learn something from it.

Does CHM have funding for publication?

It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish. CHM does NOT have funds to support publication costs, so this is an important step if you do not want to pay out of pocket for publishing.

Is it free to publish a case report?

Be aware that it may not be free to publish your case report. Many journals charge publication fees. Of note, many open access journals charge author fees of thousands of dollars. Other journals have smaller page charges (i.e. $60 per page), and still others will publish for free, with an "open access option".

Do you need informed consent for a case report?

Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports. The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible).

Do journals have informed consent?

Journals may have their own informed consent form that they would like you to use, so please look for this when selecting a journal. Once you've identified the case, selected an appropriate journal (s), and considered informed consent, you can collect the required information to write the case report.

What is a case report?

Case Report: A Beginner’s Guide with Examples. A case report is a descriptive study that documents an unusual clinical phenomenon in a single patient. It describes in details the patient’s history, signs, symptoms, test results, diagnosis, prognosis and treatment.

Why do we need case reports?

Case reports offer, in general a fast, easy and cheap way to report an unusual observation or a rare event in a clinical setting, as these have very small probability of being detected in an experimental study because of limitations on the number of patients that can be included.

What is an example of recovery from the passage of an iron bar through the head?

This is an interesting case of a construction foreman named Phineas Gage. [ Source] In 1848, due to an explosion at work, an iron bar passed through his head destroying a large portion of his brain’s frontal lobe.

Is a case report causal?

Observing a relationship between an exposure and a disease in a case report does not mean that it is causal in nature. The absence of a control group that provides a benchmark or a point of reference against which we compare our results. A control group is important to eliminate the role of external factors which can interfere with ...

Is a case report representative of the entire population?

So, results from a case report cannot be representative of the entire population.

What to ask for in a case report?

It is often best to ask for informed consent and the patient’s perspective before you begin writing your case report. Appendices (If indicated). Submission to a scientific journal. Follow author guidelines and journal submission requirements when writing and submitting your case report to a scientific journal.

Do you need informed consent for a journal?

The patient should provide informed consent (including a patient perspective) and the author should provide this information if requested. Some journals have consent forms which must be used regardless of informed consents you have obtained. Rarely, additional approval (e.g., IRB or ethics commission) may be needed.

What is case report?

Abstract. A case report is a description of important scientific observations that are missed or undetectable in clinical trials. This includes a rare or unusual clinical condition, a previously unreported or unrecognized disease, unusual side effects to therapy or response to treatment, and unique use of imaging modalities or diagnostic tests ...

What is the role of case reports in medical imaging?

Two main roles are recognized for case reports published in medical imaging and radiology journals: as sources of new knowledge and as important means for education and learning.

What should be the introduction of a case report?

The introduction should be concise and immediately attract the attention and interest of the reader. The introduction should provide background information on why the case is worth reading and publishing, and provides an explanation of the focus of the case report, for example: “We present/report a case of ….”.

Why are case reports important?

Although case reports are regarded by some as the lowest (some even do not list the case reports at all) in the hierarchy of evidence in the medical literature, publishing case reports allow for anecdotal sharing of individual experiences , providing essential sources of information for the optimum care of patients.

Should the author's interpretation or inferences be avoided in the body of a case report?

The author's own interpretation or inferences should be avoided in the body of a case report. Tables/figures should be used to reveal chronological findings or to compare observations using different methods.

Is a case report a literature review?

The discussion section of a case report is not designed to provide a comprehensive literature review and citation of all references; therefore, all the references cited should be critically evaluated. Any limitations of the case should be stated and the significance of each limitation described.

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Advantages of Case Reports

  • Case reports offer, in general a fast, easy and cheap way to report an unusual observation or a rare event in a clinical setting, as these have very small probability of being detected in an experimental study because of limitations on the number of patients that can be included. These events deserve to be reported since they might provide insights...
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Limitations of Case Reports

  • Observing a relationship between an exposure and a disease in a case report does not mean that it is causal in nature. This is because of: 1. The absence of a control group that provides a benchmark or a point of reference against which we compare our results. A control group is important to eliminate the role of external factors which can interfere with the relationship betw…
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Real-World Examples of Case Reports

  • Example 1: Normal plasma cholesterol in an 88-year-old man who eats 25 eggs a day
    This is the case of an old man with Alzheimer’s disease who has been eating 20-30 eggs every day for almost 15 years. [Source] The man had an LDL-cholesterol level of only 142 mg/dL (3.68 mmol/L) and no significant clinical atherosclerosis (deposition of cholesterol in arterial walls)! H…
  • Example 2: Recovery from the passage of an iron bar through the head
    This is an interesting case of a construction foreman named Phineas Gage. [Source] In 1848, due to an explosion at work, an iron bar passed through his head destroying a large portion of his brain’s frontal lobe. He survived the event and the injury only affected 1 thing: His personality! Af…
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References

  1. Sayre JW, Toklu HZ, Ye F, Mazza J, Yale S. Case Reports, Case Series – From Clinical Practice to Evidence-Based Medicine in Graduate Medical Education. Cureus. 2017;9(8):e1546. Published 2017 Aug 7...
  2. Nissen T, Wynn R. The clinical case report: a review of its merits and limitations. BMC Res Notes. 2014;7:264. Published 2014 Apr 23. doi:10.1186/1756-0500-7-264.
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Further Reading