how to write a case report of a patient

by Prof. Nolan Cronin I 5 min read

How to write a patient case report - PubMed

24 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


  • Format of the patient case report. Case reports should encompass the following five sections: an abstract, an introduction and objective with a literature review, a description of the 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.
  • Conclusion. Patient case reports are valuable resources of new and unusual information that may lead to vital research.
  • Appendix A—Criteria for publishable case reports. Use technology to improve patient outcomes.
  • Appendix B—Guidelines for writing patient case report manuscripts. (The following checklist is comprehensive; some items may not apply to all types of case reports.) □ Introduction and objective.

III. Patient case presentation
  1. Describe the case in a narrative form.
  2. Provide patient demographics (age, sex, height, weight, race, occupation).
  3. Avoid patient identifiers (date of birth, initials).
  4. Describe the patient's complaint.
  5. List the patient's present illness.
  6. List the patient's medical history.
Oct 1, 2006

How to write a report based on a case study?

  • The title should contain a phrase like case study or case report, so that readers understand what type of study it is.
  • An effective title might also say what condition the patient had, how it was treated, and whether the outcome was successful.
  • Most titles are less than 10 words long.

Can I write my own case report?

You can write a report and ask the judge to consider it, and if the circumstances are complex, probably should — same if the damages are composed of more than a few items, and you can attach receipts, etc. Remember, whatever you submit to the judge you must submit an exact copy to the other side, so you will need a total of three copies (one for yourself).

How to actually get your patients to write a review?

Are you posting a comment because:

  • You want to help others by providing genuine insights?
  • You are furious and feel the need to vent?
  • You are seeking revenge for a high bill or a canceled appointment?
  • You are a serial poster who simply likes posting across all social platforms?

Where can I publish a case report?

Tools to Use When Deciding Where to Publish

  • Jane (Journal / Author Name Estimator) Search for journals that might be interested in publishing your article. ...
  • Journal Citation Reports Weighs and ranks journals by a number of criteria. ...
  • Journal Citation Reports Quick Reference Cards Handout showing how to use JCR including definitions of various metrics and screenshots.

More items...

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What is case report example?

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.

How do you write an introduction for a case report?

First, you want to introduce the topic not discuss the actual case. Therefore, you should not include details about your client until the case description section. The introduction should only give the background on why this case report was written and some background on the condition of interest.

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 prepare a patient case?

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 long should case reports be?

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.

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.

How is a report written?

Reports typically stick only to the facts, although they may include some of the author's interpretation of these facts, most likely in the conclusion. Moreover, reports are heavily organized, commonly with tables of contents and copious headings and subheadings.

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 do you write a case study example?

A case study exampleStart with a clear headline. This should be like a newspaper headline that gives the most important information. ... Provide a snapshot. ... Introduce the client. ... State the problem, consequences, & hesitations. ... Describe the solution. ... Share the results & benefits. ... Conclude with words of advice and a CTA.

What is patient report?

Relationship between PROs, PROMs, and PRO-PMs. 1.1 PATIENT-REPORTED OUTCOMES (PROS) CMS defines a PRO as any report of the status of a patient's health condition or health behavior that. comes directly from the patient, without interpretation of the patient's response by a clinician or. anyone else.

What is the format of case study?

Follow these rules for the draft: Your draft should contain at least 4 sections: an introduction; a body where you should include background information, an explanation of why you decided to do this case study, and a presentation of your main findings; a conclusion where you present data; and references.

How do you start a case presentation?

How to Write a Case Study: a 4-Step FrameworkIdentify the Problem. Every compelling case study research starts with a problem statement definition. ... Explain the Solution. ... Collect Testimonials. ... Package The Information in a Slide Deck.

What is an introduction in case report?

Introduction. 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 an introduction?

How to Write a Good IntroductionKeep your first sentence short.Don't repeat the title.Keep the introduction brief.Use the word “you” at least once.Dedicate 1-2 sentences to articulating what the article covers.Dedicate 1-2 sentences to explaining why the article is important.More items...•

How long should a case report Introduction be?

Introduction. Content should be brief and less than 3 paragraphs: State the purpose of the case report. Provide background information and pertinent definitions.

How do you end a case study introduction?

Give a brief summary of previous case studies you reviewed and how you contributed to the expansion of current knowledge. End by explaining how your case study and its findings could form part of future research on the topic.

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).

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 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.

How to select a case for the case report?

Every case is unique in a way, but every case cannot be reported. I am giving you some pointers on how to select a good case and ensure it gets published after all those writing efforts – the next time you go to your clinic, document the case if you observe any of the following:

Structure of a case report

Case reports are shorter than most other types of articles. They consist of the following six sections:

Abstract

An abstract is not compulsory, but it is always better if you give one. The abstract should summarize the case, the problem it addresses, and the message it conveys. Abstracts of case studies are usually short (preferably not more than 200 words) and unstructured (not subdivided into different headings but a single paragraph).

Introduction

The introduction gives a brief overview of the problem that the case addresses, citing relevant literature where necessary. It should provide background information on why the case is worth reading and publishing. The introduction generally ends with a single sentence describing the diagnosis and treatment plan executed.

Case description

The case description or summary is the focus of the case report. The case should be best presented in enough detail for the reader to establish his or her own conclusions about the case's validity.

Discussion

The discussion is the most important section of the case report. It interprets the key findings of the case report, contrasts the case report with what is already known in the literature to justify its uniqueness and draws clinically useful conclusions.

Conclusion

The author should provide the main conclusion of the case report based on the evidence reviewed in the discussion section. A concise statement of the lesson to be learnt from the case could be stated. Here, the author can give suggestions and recommendations to clinicians, teachers, or researchers.

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.

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.

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Abstract

Format of The Patient Case Report

  • Case reports should encompass the following five sections: an abstract, an introduction and objective with 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.6,7 Supplementary parts such as tables, figures, graphs, and illustratio...
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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 merit of the case report and the …
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Conclusion

  • Patient case reports are valuable resources of new and unusual information that may lead to vital research.
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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 humanistic lessons to the health …
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