good patient case report example

For example, a case report of an adverse drug event or medication error should include a review of an adverse reaction database such as Clin-Alert or databases that review pharmacy publications such as International Pharmaceutical Abstracts and Iowa Drug Information Service.

Full Answer

What should be in a patient case report?

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.

How to write a patient case analysis?

Your patient case analysis is an investigation of a medical plight or case. When you present your findings, you have to balance the description of the situation and the detailing of the analyses. You have to illustrate how and why you came to a conclusion by providing the necessary background information.

What makes a good case study report?

Case reports are great to get first impressions that can generate new hypotheses (e.g. detecting a potential side effect of a drug) or challenge existing ones (e.g. shedding the light on the possibility of a different biological mechanism of a disease).

What is a case report for medical students?

This page is intended for medical students, residents or others who do not have much experience with case reports, but are planning on writing one. What is a case report? A medical case report, also known as a case study, is a detailed description of a clinical encounter with a patient.

How do you write a patient case report Example?

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 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.

How do you write a patient case study?

Throughout the whole writing process, you should support your case with evidence by citing information properly.Title.Abstract.Introduction.Client Characteristics.Examination Findings.Clinical Hypothesis/Impression.Intervention.Outcome.More items...

How do you write an introduction for a case report?

The introduction gives a brief overview of the problem that the case addresses, citing relevant literature where necessary. The introduction generally ends with a single sentence describing the patient and the basic condition that he or she is suffering from.

How do you write a patient medical report?

HOW TO WRITE A MEDICAL REPORTKnow that a common type of medical report is written using SOAP method. ... Assess the patient after observing her problems and symptoms. ... Write the Plan part of the Medical report. ... Note any problems when you write the medical report.More items...

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.

What is an example of a case study?

Prospective case study methods are those in which an individual or group of people is observed in order to determine outcomes. For example, a group of individuals might be watched over an extended period of time to observe the progression of a particular disease.

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 long is a case report?

1500 wordsThe 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.

How do you write a conclusion for a case report?

What to put in your case study conclusions. A case study ending is your opportunity to bring some closure to the story that you are writing. So, you can use it to mention the status of the project (e.g., is it ongoing or has it ended?) and then to demonstrate the impact that your work has had.

How do you write a case report PDF?

The sections of the case report are the title, abstract with keywords, introduction, case description, discussion with conclusions and references. The case report should be clear, concise, coherent, and must convey a crisp message. Common pitfalls and mistakes will be discussed.

How do you write a case?

Step 1: Case Origin Identify the needs Step 2: Establishing the needs The search for specific issues, ideas, and individuals or organizations that might supply the case information Step 3: Initial Contact The establishment of access to material on the case subject Step 4: Data Collection The gathering of the relevant ...

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 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 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 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.

Do I need IRB approval for case reports?

If this is true for your case report, then it most likely does not require IRB approval because it not considered research. If you have more than one patient, your study could qualify as a Case Series, which would require IRB review. If you have questions, you chould check your local IRB's guidelines on reviewing case reports.

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).

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.

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…

See more on quantifyinghealth.com

References

Further Reading

Abstract

Format of The Patient Case Report

Summary

Conclusion

Appendix A—Criteria For Publishable Case Reports

• Publishable patient case reports include cases that: 1. Advance medical science and spawn research; 2. Describe rare, perplexing, or novel diagnostic features of a disease state; 3. Report therapeutic challenges, controversies, or dilemmas; 4. Describe a new surgical procedure; 5. Report how a drug can enhance a surgical procedure; 6. Teach humanis...

See more on academic.oup.com