case report patient

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.

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.

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...•

What is meant by 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).

Do you need patient permission for case report?

Don't publish a case report without the patient's consent As explained above, informed patient consent is mandatory for the publication of your case reports. Ignoring this requirement can result in a rejection for your work and worse, ruin your relationship and reputation with patients.

How do you introduce a patient in a case study?

First, we describe the complaint that brought the patient to us. It is often useful to use the patient's own words. Next, we introduce the important information that we obtained from our history-taking. We don't need to include every detail – just the information that helped us to settle on our diagnosis.

What is a patient case?

present a patient case. 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.

What is the importance of case reports?

Case reports are valuable resources of unusual information that may lead to new research and advances in clinical practice. Many journals and medical databases recognize the time-honored importance of case reports as a valuable source of new ideas and information in clinical medicine.

Can medical students write case reports?

Case reports are written with the goal of sharing information for medical, scientific, or educational purposes. They often serve as medical or even undergraduate students' first experience with medical writing and they provide a solid foundation for manuscript preparation and publication.

How do you take consent from a patient to a case report?

Consent to use a patient's story should be obtained prior to publishing the report wherever possible. This consent should be obtained directly and preferably in writing from the individual affected. A suitable consent form is provided here. To not obtain consent for a case report requires justification.

Is case report A research?

Case reports and case series or case study research are descriptive studies that are prepared for illustrating novel, unusual, or atypical features identified in patients in medical practice, and they potentially generate new research questions.

What is a patient case study?

A clinical case report or case study is a type of academic publication where medical practitioners share patient cases that are unusual or haven't been described before. Acquiring patient consent and maintaining patient anonymity are essential aspects of writing a clinical case report.

How do you give a patient presentation?

TipsInclude only the most essential facts; but be ready to answer ANY questions about all aspects of your patient.Keep your presentation lively.Do not read the presentation!Expect your listeners to ask questions.Follow the order of the written case report.Keep in mind the limitation of your listeners.More items...•

How do you summarize patient history?

List your medical, surgical and family histories:All known medical diagnoses, past and present.All surgeries, with name of surgery, date, and outcome.Allergies, especially to medications, and what reaction you had. ... Names, specialties, and phone numbers of any physicians who are still following you.More items...

What type of study is a case report?

Case reports and case series or case study research are descriptive studies that are prepared for illustrating novel, unusual, or atypical features identified in patients in medical practice, and they potentially generate new research questions.

What is the difference between case study and case report?

Case studies are widely used in psychology to provide insight into unusual conditions. A case study, also known as a case report, is an in depth or intensive study of a single individual or specific group, while a case series is a grouping of similar case studies / case reports together.

What is case report in study design?

An article that describes and interprets an individual case, often written in the form of a detailed story. 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.

What is case series and case report?

A case report is a detailed report of the diagnosis, treatment, response to treatment, and follow-up after treatment of an individual patient. A case series is group of case reports involving patients who were given similar treatment.

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 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.

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 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.

1. Talk to Colleagues

If you encounter a striking or unique patient case in your clinical practice that seems worthy of a case report, talk to your colleagues and senior clinicians to determine if the patient case is of interest for further research and documentation in the form of a case report.

2. Conduct Research

Once you have determined the viability of a patient case for a case report, conduct research to ensure this case will present new and/or unique findings to the wound care community. Use online medical databases to research peer-reviewed journal articles to review similar cases and/or the condition (s) presenting in your patient.

3. Seek Permission

Gain the permission of the patient (s), or in the case of a deceased patient, the next-of-kin. You may also need to seek permission from the patient's primary case manager depending on your position and facility protocol.

4. Compile the Patient Background and History

Create the presentation of the patient case and wound care treatment. Include the clinical background of the case. It is in this section that you will describe the case and start with the basics:

5. Document Wound Assessment

Once you have set the stage, follow up with the wound assessment. Describe the location, etiology, wound history, size, and appearance of tissue, exudate and periwound skin.

6. Describe Treatment Protocol

The next section should address and explain the treatment protocol that was implemented. Describe your wound management approach here. List what treatment intervention and/or product (s) were used, how much, frequency of dressing change and any other pertinent information.

7. Document Results

Describe and detail what wound changes you observed and at what time intervals during the treatment process. Discuss how many days transpired until closure was observed.

Simple Medical History

Once you have collected these medical data, you can record them as a pdf by using this medical history PDF template. In addition, you don't need to be worried about the safety of data, because our forms are HIPAA compliant.

Doctors Note

Validate the medical condition of the patient by giving them a Doctor's Note Template. This PDF template shows the medical diagnosis of the patient and medical treatment.

Patient Medical Record

Medical History Record PDF template lets you collect the patient's data such as personal information, contact information in an emergency case, general medical history. By using this sample, the doctor ensures the patient's better care and treatment.

Short Medical History

Medical History Record PDF template is mostly used in order to provide significant information about the health history, care requirements, and risk factors of the patient to doctors. It is for collecting data from the patients.

Veterinary Hospital Treatment Sheet

Veterinary Hospital Treatment Sheet helps both the hospital and pet owners in understanding and tracking a pet's treatment process. Just like any other hospitals, keeping patient's treatment records is necessary to monitor progress and make sure proper treatment is given.

COVID-19 Vaccine Administration Record

Keep track of patient vaccination records online. Secure with GDPR, CCPA, and optional HIPAA compliance. Download or print as PDFs. Free, easy-to-customize template.

Dental Health Record

The Dental Health Record Template is easy for patients to fill out and designed to get the doctor the most important information. Patients can fill out their information on a computer or tablet using our Dental Health Record Template.

Abstract

Format of The Patient Case Report

Summary

• Patient case reports are valuable resources of new and unusual information that may lead to vital research and advances in clinical practice that improve patient outcomes. Case reports should contain an abstract and four sections—an introduction, case presentation, discussion, and conclusion. The introduction provides the subject, purpose, and meri...

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Conclusion

Appendix A—Criteria For Publishable Case Reports

Advantages of Case Reports

Limitations of Case Reports

• Part 1 — Working Title, WHAThappened: Timeline and Narrative
  1. Develop a descriptive and succinct working title that describes the phenomenon of greatest interest (symptom, diagnostic test, diagnosis, intervention, outcome). 2. WHAT happened. Gather the clinical information associated with patient visits in this this case report to create a timeline…
• Part 2 — WHYit might have happened: Introduction, Discussion, Conclusion
  1. The introduction should briefly summarize why this case report is important and cite the most recent CARE article (Riley DS, Barber MS, Kienle GS, AronsonJK, et al. CARE guidelines for case reports: explanation and elaboration document. JClinEpi 2017 Sep;89:218-235. doi: 10.1016/jclin…

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Real-World Examples of Case Reports

References

• 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...

See more on quantifyinghealth.com

Further Reading