Case Report: A Beginner’s Guide with Examples
19 hours ago Definition of Case Report. The clinical case report describes and analyzes the diagnosis and/or the management of one or two patients. It is the first line of evidence in health care and forms the base of the evidence-based pyramid [1,4,5]. Some case reports also contain a literature review of previously reported cases [6]. >> Go To The Portal
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
- Work on Your Introduction Select a case. You have to identify your focus and scope for the study. ...
- Get to Know the Participants You can have one or multiple case participants. ...
- Perform Data Analyses Method Your results will depend on your interpretation of the raw data. ...
- 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. ...
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.
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).
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.
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 the purpose of patient case study?
Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.
What is the purpose of the case report form?
A Case Report Form (CRF) is a printed or electronic document that is created and used in clinical trial research to capture standardised clinical data from each patient separately and to transfer it to Data Management.
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 should a patient case study include?
Case: This section provides the details of the case in the following order:Patient description.Case history.Physical examination results.Results of pathological tests and other investigations.Treatment plan.Expected outcome of the treatment plan.Actual outcome.
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 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 are the 3 methods of case study?
He has helpfully characterised three main types of case study: intrinsic, instrumental and collective[8]. An intrinsic case study is typically undertaken to learn about a unique phenomenon. The researcher should define the uniqueness of the phenomenon, which distinguishes it from all others.
report
a prepared account of an event, investigation, or evaluation, usually for formal presentation to an authority or group.
case report
A formal summary of a unique patient and his or her illness, including the presenting signs and symptoms, diagnostic studies, treatment course, and outcome.
What is a good case report?
A good case report will be clear about the importance of the observation being reported. If multiple case reports show something similar, the next step might be a case-control study to determine if there is a relationship between the relevant variables.
What is unique case?
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. Case reports are considered the lowest level of evidence, ...
What is a case report?
A case report is an observational, descriptive research design that carefully recorded unbiased observations. The case should be described in details so that others can identify similar cases. The case report should provide information on the patient’s socio-demographics (e.g. age, sex, ethnicity, race, employment status, social situation), medical history, diagnosis, prognosis, previous treatments, past and current diagnostic test results, medications, psychological tests, clinical and functional assessments, and current intervention. Authors explore and infer, not confirm, deduce, or prove. They cannot demonstrate causality or argue for the adoption of a new treatment approach.
What are the limitations of case reports?
Case reports have certain limitations as inherent properties of the design itself and include the following [17-22]: 1 regarded as low-level evidence as the observations may be subject to bias. 2 lacks generalizability. 3 lacks denominator data that are necessary to calculate the rate of disease. 4 lacks a comparison or control group to compare outcomes and have little statistical validity. 5 often describe highly select individuals who may not represent the general population. Since the care rendered to one patient may not produce a similar change in another patient, case reports should not be generalized but for the patient reported. 6 infrequently cited, and therefore, publishing case reports are likely to decrease the journal’s impact factor. This has led many editors to remove case report sections from their journals.
What is case series study?
Case-series studies are simply descriptive reports illustrating observations of interest in many usually consecutive, patients with similar diagnoses or undergoing the same procedure followed over time.
Is a control patient a longitudinal study?
There are no control patients involved or initial hypotheses presented, although such studies frequently result in hypotheses that lead to further studies. Because they describe the disease course of the patients involved, they are longitudinal in design.
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?
A case report is an unsystematic clinical observation that states the outcome or response of a single patient to a diagnostic strategy or treatment . Case reports serve to document and share novel cases amongst the medical community for educational purposes.
When case reports describe or discuss unique or rare circumstances, as they often do, it may be difficult or impossible to answer
When case reports describe or discuss unique or rare circumstances, as they often do, it may be difficult or impossible to de-identify those cases such that there is no reasonable expectation that the individuals included can be identified, so patient authorization generally would be required.
What is PHI in healthcare?
This is known as safe harbor de-identification.
When safe harbor de-identification is not possible or the opportunity to identify the patient exists, even after de-ident
When safe harbor de-identification is not possible or the opportunity to identify the patient exists, even after de-identification, the expert determination method for de-identification can be considered. For purposes of de-identification, an expert is defined as: A person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable:
Is PHI de-identified under HIPAA?
It is important to understand that determining whether data are de-identified under HIPAA is a more restrictive determination than determining whether private information is individually identifiable under the Common Rule. The HIPAA rule considers PHI as any information that may identify an individual; was created or received by a member of a HIPAA covered entity; and relates to the individual's past, present, or future physical/mental health or condition, health care, or payment for health care. HIPAA recognizes two methods for de-identification of data.
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 imp…
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…
References
- 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...
- 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.
Further Reading
Definition
Advantages
- Can help in the identification of new trends or diseases
- Can help detect new drug side effects and potential uses (adverse or beneficial)
- Educational – a way of sharing lessons learned
- Identifies rare manifestations of a disease
Disadvantages
- Cases may not be generalizable
- Not based on systematic studies
- Causes or associations may have other explanations
- Can be seen as emphasizing the bizarre or focusing on misleading elements
Design Pitfalls to Look Out For
- The patient should be described in detail, allowing others to identify patients with similar characteristics. Case reports should include carefully recorded, unbiased observations. Case reports should explore and infer, not confirm, deduce, or prove. They cannot demonstrate causality or argue for the adoption of a new treatment approach.
Fictitious Example
- A physician treated a young and otherwise healthy patient who came to her office reporting numbness all over her body. The physician could not determine any reason for this numbness and had never seen anything like it. After taking an extensive history the physician discovered that the patient had recently been to the beach for a vacation and had used a very new type of spray sun…
Related Terms
- Case Series A report about a small group of similar cases. Preplanned Case-Observation A case in which symptoms are elicited to study disease mechanisms. (Ex. Having a patient sleep in a lab to do brain imaging for a sleep disorder).
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