example of a patient case report

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 write a simple case report?

Ten Steps to Writing an Effective Case Report (Part 1)Step 1: Identify the Category of Your Case Report. ... Step 2: Select an Appropriate Journal. ... Step 3: Structure Your Case Report According to the Journal Format. ... Step 4: Start Writing. ... Step 5: Collect Information Related to the Case.

What are the characteristics of a good case report?

Case reports should be short and focused, with a limited number of figures and references. There are usually a restricted number of authors. The structure of a case report usually comprises a short unstructured (or no) abstract, brief (or no) introduction, report of the case, and discussion [Table 1].

How do you present a patient case?

Case Presentation. The case report should be chronological and detail the history, physical findings, and investigations followed by the patient's course. At this point, you may wish to include more details than you might have time to present, prioritizing the content later.

How do I start writing a report?

Here are some steps to follow when writing a report:Decide on terms of reference.Conduct your research.Write an outline.Write a first draft.Analyze data and record findings.Recommend a course of action.Edit and distribute.

How do you start a report introduction?

The introduction should:discuss the importance or significance of the research or problem to be reported.define the purpose of the report.outline the issues to be discussed (scope)inform the reader of any limitations to the report, or any assumptions made.

What are information contained in a case report?

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 long is a case report?

The word count for case report may vary from one journal to another, but generally should not exceed 1500 words, therefore, your final version of the report should be clear, concise, and focused, including only relevant information with enough details.

What does case report form include?

What is a Case Report Form? A CRF is a set of documents that collects data and information from a clinical trial. The CRF is used by the study sponsor to capture and retain important data in the clinical trial. CRFs are usually electronic but may also be created in paper form.

How do you start a case presentation?

You should begin every oral presentation with a brief one-liner that contains the patient's name, age, relevant past medical history, and chief complaint. Remember that the chief complaint is why the patient sought medical care in his or her own words. An example of an effective opening is as follows: “Ms.

How do you structure a case presentation?

SUMMARYSET THE STAGE.PROVIDE ONLY INITIAL CUES AT FIRST.ASK FOR HYPOTHESES AND WRITE THEM UP ON THE BLACKBOARD.ALLOW THE AUDIENCE TO ASK FOR INFORMATION.HAVE THE AUDIENCE RE-FORMULATE THEIR LIST OF HYPOTHESES.FACILITATE A DISCUSSION ABOUT REASONING.ALLOW ANOTHER ROUND OF INFORMATION SEEKING.More items...

What are the components of patient case presentation?

Highlighted in this chapter are the essential components of the presentation: the chief complaint, the history of present illness (HPI), the past medical history, the family and social history, the review of systems, and finally, the physical examination findings.

What is a patient care report?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the inf...

What should not be written in a patient care report?

What should be avoided in a patient care report is making up the information that is not true to the patient. This is why you have to be very caref...

Who is in charge of reading the patient care report?

The person or the people who will be reading the report are mostly medical authorities. When you are going to be passing this kind of report, make...

What Is a Patient Care Report?

We often hear of care reports based on by medical teams or by medical authorities. Yet, we are not sure how this differs from the kind of report that is given to us by the same people. So this is the time to make it as clear as possible.

How to Write a Patient Care Report?

Where do you even begin when you write a patient care report? A lot of EMS or EMTs do know how to write one since they are trained to do so.

What is a patient care report?

A patient care report is a document made mostly by the EMS or EMTs. This documented report is done after getting the call. This consists of the information necessary for the assessment and evaluation of a patient’s care.

What should not be written in a patient care report?

What should be avoided in a patient care report is making up the information that is not true to the patient. This is why you have to be very careful and very meticulous when writing these kinds of reports. Every detail counts.

Who is in charge of reading the patient care report?

The person or the people who will be reading the report are mostly medical authorities. When you are going to be passing this kind of report, make sure that you have all the information correctly. One wrong information can cause a lot of issues and problems.

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 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 .

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.

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).

Does HIPAA apply to case reports?

First, you will be collecting protected health information, thus HIPAA applies to case reports. Spectrum Health has created a very helpful guidance document for case reports, which you can see here: Case Report Guidance - Spectrum Health. While this guidance document was created by Spectrum Health, the rules and regulations outlined could apply ...

On this page

This is a fictitious case that has been designed for educative purposes.

Background

Mrs Beryl Brown (01/11/30) is an 85 year old woman who was admitted to the Hume Hospital by ambulance after being found by her youngest daughter lying in front of her toilet. Her daughter estimates that she may have been on the ground overnight.

Social history

I understand that Mrs Brown has been residing in her own home, a two story terrace house, in Melbourne for almost 60 years. She has lived alone since her husband died two years ago following a cardiac arrest. She has two daughters. The youngest daughter Jean has lived with her for the past year, after she lost her job.

Current function

Mrs Brown has a history of Alzheimer’s disease; type II diabetes – insulin dependent; hypertension; high cholesterol and osteoarthritis. She has had two recent admissions to hospital for a urinary tract infection and a fall in the context of low blood sugars.

The current risks

Mrs Brown is at high risk of experiencing falls. She has reduced awareness of the left side of her body and her ability to plan and process information has been affected by her stroke. She is now requiring one to two people to assist with all her tasks of daily living and she lacks insight into these deficits.

Attempts to trial least restrictive options

We have convened two family meetings with Mrs Brown, both her daughters and several members of the multi-disciplinary team. The outcome of the first meeting saw all parties agree for the ward to provide personalised carer training to Jean with the aim of trialling a discharge home.

Recommendation

The treating team believe they have exhausted all least restrictive alternatives and that a guardianship order is required to make a decision on Mrs Brown’s discharge destination and access to services. The team recommend that the Public Advocate be appointed as Mrs Brown’s guardian of last resort.

Advantages of Case Reports

Limitations of Case Reports

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

Further Reading