sample patient case report

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.

Full Answer

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...•

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.

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 present a patient's case?

Case: Tom MurphyPresenting problem. You should start with a sentence that includes the patient's name, sex (Mr/Ms), age, and presenting symptoms. ... History of presenting problem. ... Medical and surgical history. ... Drugs. ... Family history. ... Social history. ... Review of systems. ... Findings on examination.More items...•

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.

What is the format of a report?

Reports are divided into sections with headings and subheadings. Reports can be academic, technical, or business-oriented, and feature recommendations for specific actions. Reports are written to present facts about a situation, project, or process and will define and analyze the issue at hand.

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 write a case report introduction?

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.

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 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 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.

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.

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 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.

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 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 Is a Case Report?

There is a widespread misconception in business that a case report is a thick, corporate jargon-filled manuscript that experts and professional consultants can only develop. A case report is created for an organization to provide documented justification for the progress of a project or whether it should be undertaken.

Benefits of a Case Report

A case report is a detailed investigation into a specific situation. The research could focus on a single person, a company, an event, or a group. The study entails gathering detailed information about the individual entity using a variety of ways. Two of the most prevalent methods of data analysis are interviews and observation.

Components of a Case Report

As previously indicated, a justification can be used only within the business to secure permission for simple budget or money requests, duties, or specific projects, as well as loans. Explanations usually have the same basic features regardless of the need.

How To Create a Case Study Report

To assist you in arming your prospects with credible information, we’ve created a step-by-step guide on how to develop adequate case studies for your business — as well as free case study templates for you to use. If you’re interested in making one, here are the steps.

What constitutes a case report?

A case report is a research design in which an unexpected or unusual event is recounted in a complete account of a single patient’s findings, clinical course, and prognosis, which may or may not be accompanied by a literature analysis of previously known occurrences.

Are case studies useful?

Case reports are excellent sources of unexpected information that could lead to new research and clinical advancements. Case reports have long been recognized as a valuable source of fresh ideas and information in clinical care, and many publications and medical databases recognize this.

Are case reports supported by evidence?

Case reports are the simplest form of evidence, but they are also the first line of defense because new issues and ideas develop. That’s why they’re at the bottom of our pyramid. The significance of the observation being reported will be evident in a robust case report.

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.

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

Conclusion

Appendix A—Criteria For Publishable Case Reports