29 hours ago How to write a patient case report Am J Health Syst Pharm. 2006 Oct 1;63(19):1888-92. doi: 10.2146/ajhp060182. Author Henry Cohen 1 Affiliation ... 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 … >> Go To The Portal
Assess the following before and after cast application: 1 Evaluate the client’s pain, noting severity, nature, exact location, source and alleviating and exacerbating factors. 2 Access neurovascular status. 3 Inspect for and document any skin lesions, discoloration, or no removable foreign material. More items...
(1) Avoid resting cast on hard surfaces or sharp edges that may dent the cast and cause pressure areas. (2) Never use a coat hanger or other foreign object to "scratch" inside the cast. This may cause skin damage and infection. (3) Report any danger signs to the nursing staff immediately.
Teach the client appropriate cast care, depending on the type of cast. Encourage safety precautions (e.g. avoid walking on wet floors, watch throw rugs, be careful with stairs). Teach the client skin care and muscle-strengthening exercises for the affected body part after cast removal. Encourage mobility and active participation in self-care.
a. Although a patient with an arm or leg cast is much more self-reliant than a patient in a body or spice cast, it is a nursing responsibility to monitor all patients and assist as needed. Nursing management includes the following actions to assess the effectiveness of the cast.
The most common reasons for publishing a case are the following: 1) an unexpected association between diseases or symptoms; 2) an unexpected event in the course observing or treating a patient; 3) findings that shed new light on the possible pathogenesis of a disease or an adverse effect; 4) unique or rare features of ...
How to write a case reportDetermine if your topic is significant and unique enough to write about.Choose the journal where you want your case report featured.Ask a physician to collaborate with you.Request permission from the patient.Compile all your paperwork, research and relevant information.More items...•
Case reports and studies intended for quality improvement are often considered not research and do not need IRB approval. Nevertheless, there should be some processes of clearing those studies with respect to ethical handling of patients and related data.
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.
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.
Under HIPAA, a case report is an activity to develop information to be shared for medical/educational purposes. Although the use of protected health information to prepare the paper does not require IRB review, the author of a case report must comply with HIPAA.
Some studies that do not require ethical approval include those involving information freely available in the public domain (e.g. published biographies, newspaper accounts), and the analysis of datasets, either open source or obtained from other researchers, where the data are properly anonymised and informed consent ...
Although most institutions require IRB approval, consent is usually not required as the IRB will ensure that steps are taken to ensure the anonymity of the data. The answer would be "it depends" on what you mean by retrospective.
A: Yes. Approval from a formally constituted review board (Institutional Review Board or ethics committee) is required for all studies involving people, medical records, and human samples. Q: Do I need patient consent for the use of retrospective data? A: Informed consent by participants should always be sought.
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.
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.
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).
The abstract of a patient case report should succinctly include the four sections of the main text of the report. The introduction section should provide the subject, purpose, and merit of the case report.
Patient case reports are valuable resources of new and unusual information that may lead to vital research.
A case report ends with a conclusion or with summary points, depending on the journal's specified format. This section should briefly give readers the key points covered in the case report. Here, the author can give suggestions and recommendations to clinicians, teachers, or researchers. Some journals do not want a separate section for the conclusion: it can then be the concluding paragraph of the Discussion section.
Abstracts of case studies are usually very short, preferably not more than 150 words.
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. Some reports contain an extensive review of the relevant literature on the topic. The case report is a rapid short communication between busy clinicians who may not have time or resources to conduct large scale research.
The most common reasons for publishing a case are the following: 1) an unexpected association between diseases or symptoms; 2) an unexpected event in the course observing or treating a patient; 3) findings that shed new light on the possible pathogenesis of a disease or an adverse effect; 4) unique or rare features of a disease; 5) unique therapeutic approaches; variation of anatomical structures.
Patient anonymity is also an important requirement. Remember not to disclose any information that might reveal the identity of the patient. You need to be particularly careful with pictures, and ensure that pictures of the affected area do not reveal the identity of the patient.
Informed consent in an ethical requirement for most studies involving humans, so before you start writing your case report, take a written consent from the patient as all journals require that you provide it at the time of manuscript submission. In case the patient is a minor, parental consent is required. For adults who are unable to consent to investigation or treatment, consent of closest family members is required.
Once you have a potential case, how would you know if this is an appropriate for reporting or not? Especially if you are a novice physician, once you encounter a possible case and you are suspecting if this patient fulfills one of those criteria which are described in Table 1. The first step is a high index of suspicion; keep your eyes open for every case, once you suspect a case then ask your colleagues either directly or in a group related to the same discipline, locally, to confirm that this could be a case report. The next step would be asking an expert from the national or international medical community about this case scenario, get their opinion and feedback, including the appropriateness of reporting this case. Once the feedback is positive, perform extensive literature search, through PubMed, Embase, Google Scholar, and databases for case reports to ensure that you retrieve all available information on this topic. Do not forget to look at popular case reports which are not indexed in PubMed and read through previously published case reports that will enhance your understanding of the subject and gives you a general scaffold to prepare your own report.
The case report is a research design where an unexpected or novel occurrence is described in a detailed report of findings, clinical course, and prognosis of an individual patient, which might be, but not mandatory, accompanied by a review of the literature of other reported cases. Although case reports are considered the lowest in the hierarchy of evidence-based practice in the medical literature [Figure 1], it provides essential information for unfamiliar events and shared individual experiences, for better understanding and optimizing patient care. This approach might generate an idea or hypothesis, but it will not be confirmed unless we conduct further confirmatory quantitative experimental or observational study designs such as clinical trials or cohort studies. Despite that, case report provides the medical community with information which cannot be picked up by any other designs. Just to name a few, in 1819, James Parkinson published a case report entitled “An essay on the shaking palsy”[6] and lead to the discovery of Parkinson's disease. And in 1981, a case report was published in the literature as “Preliminary communication on extensively disseminated Kaposi sarcoma in a young homosexual man”[7] few years later, HIV from this case report was discovered. Furthermore, in 2012, Ali Zaki reported an article in New England Journal of Medicine titled “Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia” which ultimately, lead to the discovery of Middle East Respiratory Syndrome Coronavirus.[8] All those previous examples show how important is case report in the advancement of medical practice. The case report might be in the tail of the hierarchy of evidence-based medicine but if properly selected and appropriately reported it might stand a better chance of publication in high impact journals than even a clinical trial.
2. Authors name: Should not exceed more than six authors
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.[3] If a shorter version is required by the journal, then you can always edit or trim off the discussion section of your article. The general format adopted for most case reports is detailed in the following subsection and summarized as a checklist in Table 2.
Give the case an appropriate time frame in the course of the disease to observe the development over time. Wait for 6 months during multiple visits, before you start writing a case report to allow adequate time to complete the clinical course.
The clinical case report has been an integral part of medical literature throughout history. The oldest example of a preserved clinical case in medical literature is a text from an ancient Egyptian papyrus dating from the 16thto the 17thdynasty, 1600 BC, addressing the management of dislocated jawbone.[5] From Hippocratic case histories, “Epidemics” 400 BC, through Galenic case reports, in the second century AD, case reports were usually used to tell other doctors or colleagues about interesting cases they have encountered. Muslim scholars have reported case histories as well, particularly, Abu Bakr Mohamed Ibn Zakariya Al-Razi (865–929 AD), where he left a large collection of case reports in his 25-volume medical encyclopedia “Kitab Al-Hawi.”[5]
Case report, as a research design, describes important scientific observations that are encountered in a clinical setting to expand our knowledge base. Preparing a case report is far easier than conducting any other elaborative research design. Case report, with its main components, should be focused and delivers a clear message. In this article, the key components of a case report were described with the aim of providing guidance to novice authors to improve the quality of their reporting.
This is not only a waste of your precious time but also a discouragement which might prevent you from producing more case reports in the future.
This can be accomplished by arranging the events in chronological order, being specific about your differential diagnostic considerations, elucidating the arguments for your clinical decision-making process, and following up to round off the story neatly. This will create an imaginary journey where your readers can follow every development of the case and understand why you have performed specific tests or made certain decisions during a particular treatment.
You can also include in your case reports descriptions of actual values for blood test results, detailed dosages for medications prescribed or other variables that should be taken into account with respect to the outcome of the situation.
As a method of documenting a single clinical observation, case reports offer timely and valuable information , especially with regards to rare diseases. They show medical professionals how fellow practitioners have acted in similar situations and thus aid in the decision-making process by sharing best practices.
To assist researchers with this task, Professors Oliver Kurzai and Adilia Warris, editors of the journal Medical Mycology Case Reports shared tips on writing high impact case reports in the latest Researcher Academy webinar. We are pleased to share here some quick do’s and don’ts from the webinar.
My Pham is a Marketing and Communications Intern at Elsevier, based in Amsterdam. Her previous roles include covering economic and political news as a Foreign Correspondent for Reuters in Vietnam and Southeast Asia. She has a master’s degree in Journalism, Media and Globalisation from the University of Amsterdam.
Don’t forget, moreover that clinical practitioners are not required to, and should not reveal personal patient information to a journal that is not relevant to the case.
(1) Assess circulation by performing the blanching test and comparing the skin temperature and blanching reaction of the affected limb to that of the unaffected limb. (2) Assess the presence of sensation in the affected limb by touching exposed areas of skin and instructing ...
(1) Check the edges of the cast and all skin areas where the cast edges may cause pressure. If there are signs of edema or circulatory impairment, notify the charge nurse or physician immediately. (2) Slip your fingers under the cast edges to detect any ...
Although a patient with an arm or leg cast is much more self-reliant than a patient in a body or spice cast, it is a nursing responsibility to monitor all patients and assist as needed.
Rationale: Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; prevent contractures or atrophy and calcium resorption from disuse
Instruct him to use a cool air from a dryer to help alleviate the itch. Teach the client appropriate cast care, depending on the type of cast. Encourage safety precautions (e.g. avoid walking on wet floors, watch throw rugs, be careful with stairs).
Physical therapy (PT) or occupational therapy (OT) may be indicated for exercises to maintain and strengthen muscles and improve function. Additional modalities such as low-intensity ultrasound may be used to stimulate healing of lower-forearm or lower-leg fractures. Review proper pin and wound care.
Rationale: Provides a dry, clean area for cast application. Note: Excess powder may cake when it comes in contact with water and perspiration.
Encourage isometric exercises to strengthen muscles covered by the cast. Promote muscle-strengthening exercises for the upper body if crutches are to be used. Advise the client to promptly report cast breaks and signs and symptoms of complications (i.e. circulatory compromise, cast syndrome, and hot spots).
Report abdominal pain and distention, nausea and vomiting, elevated blood pressure, tachycardia, and tachypnea which are physiologic effects of cast syndrome. Any client who is claustrophobic is at risk for psychological cast syndrome, which includes acute anxiety and possible irrational behavior. Provide nursing care for compartment syndrome, ...
Rationale: Lessens constant pressure on same areas and minimizes risk of skin breakdown. Use of trapeze may reduce risk of abrasions to elbows and heels.
If a case report is published, many other medical professionals can use it to learn more about rare diseases or disorders to help find treatments or cures.
When writing a case report, you should provide details that are valuable and significant to the patient's disease or disorder. Many medical professionals will read this report to find important details, which is why you should ensure it's well-structured and formatted properly.
As you build a strong case report, you want to ensure you're writing a document that helps medical professionals find new and significant information. To do this, follow the tips below to write an effective case report: