patient case report example

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 does a case report include?

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 do you write a nursing case report?

How to Write a Case Study Paper for NursingThe status of the patient. Demographic data. Medical History. ... The nursing assessment of the patient. Vital signs and test results. ... Current Care Plan and Recommendations. Details of the nursing care plan (including nursing goals and interventions)

What is a case study example?

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.

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 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 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.

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 ...

How do you write a clinical case presentation?

2:2137:49Writing Clinical Case Reports - YouTubeYouTubeStart of suggested clipEnd of suggested clipSearch is twofold. The first thing is that you want to verify that your case really is unique orMoreSearch is twofold. The first thing is that you want to verify that your case really is unique or unusual and secondly you want to provide the basis for the review of the literature. That's going to be

How do you write a simple case study?

5 key steps for writing your case studyIntroduce the customer. Set the stage for your case study with an introduction. ... State the problem. Every product or service is a solution to a problem. ... Introduce your product. This is where you begin solving the problem. ... Show results. The big reveal. ... Prove it.

What should a case study look like?

Case studies usually follow a typical story structure, which means they have a beginning, middle, and end. Think of them as a “before and after” snapshot of a customer's business – complete with quotes, statistics, and images. Business case studies are often created by the marketing team and given to the sales team.

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.

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 medical case report?

A medical case report or a case report is a document that is centered around studying new medical problems, the medical history of a patient and th...

Why is a medical case report so important?

The reason why it is so important is because it gives doctors and medical practitioners the information that they need.

Who writes the medical case report?

Doctors, nurses and those who take up medical fields are often the ones who are told to write a medical case report.

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.

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.

What is case study nursing?

A nursing case study is a detailed study of an individual patient. Through this type of research, you can gain more information about the symptoms and the medical history of a patient.

What is the purpose of the status section in a medical report?

In this section, you will provide the patient’s information, such as medical history, and give the current patient’s diagnosis, condition, and treatment. Always remember to write down all the relevant information about the patient.

What should you explain in a nursing observation?

You should explain each observation that you have collected based on the vital signs and test results. You will also explain each nursing diagnosis that you have identified and determine the proper nursing care plan for the patient. 3. The Current Care Plan and Recommendations.

What is the current care plan?

The Current Care Plan and Recommendations. Describe the appropriate care plan that you can recommend to the patient based on the diagnosis, current status, and prognosis in detail, including how the care plan will affect his or her life quality.

Do you need to reassess a nursing case study?

You may need to reassess the patient depending on his progress, and the care plan may be modified based on the reassessment result. Carrying out a nursing case study can be a delicate task since it puts the life of a person at stake. Thus, it requires a thorough investigation.

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