CaseReport病例报告的书写课件

CaseReportWritingCaseReportWritingWriting:CasereportAcasereportisadetailedreportofthesymptoms,signs,diagnosis,treatmentandfollow-upofoneortwoindividualpatients.Itusuallydescribeanunusualornoveloccurrence.Writing:CasereportAcaserepWriting:CasereportCasereportspermitdiscoveryofnewdiseasesandunexpectedeffects(adverseorbeneficial)aswellasthestudyofmechanisms,andtheyplayanimportantroleinmedicaleducation.Casereportsandserieshaveahighsensitivityfordetectingnoveltyandthereforeremainoneofthecornerstonesofmedicalprogress;theyprovidemanynewideasinmedicine.(Vandenbroucke,2001)Writing:CasereportCasereporWriting:CasereportFamousscientificcasereports

ThediscoveryofAIDSinLosAngelesin1981SigmundFreudreportedonnumerouscases,includingAnnaO.,Dora,LittleHans,Ratman,andWolfmanPaulBrocareportedonlanguageimpairmentfollowinglefthemispherelesionsinthe1860sThediscoveryofcongenitalmalformationofneonatalscausedbyingestionofthalidomidebythemothersofthesebabiesWriting:CasereportFamoussciWriting:CasereportTypesofcasereportsMostcasereportsareononeofsixtopics:1)Anunexpectedassociationbetweendiseasesorsymptoms.2)Anunexpectedeventinthecourseofobservingortreatingapatient.3)Findingsthatshednewlightonthepossiblepathogenesisofadiseaseoranadverseeffect.4)Uniqueorrarefeaturesofadisease.5)Uniquetherapeuticapproaches.6)Apositionalorquantitativevariationoftheanatomicalstructures.Writing:CasereportTypesofcWriting:CasereportStagesinwritingacasereport

FindingararecaseLiteraturesearchCollectinginformationrelatedtothecase,includingconsentfromthepatientRevisingandeditingWriting:CasereportStagesinWriting:CasereportStructureofacasereport:IntroductionCasePresentationDiscussionReferencesWriting:CasereportStructure1.IntroductionTheintroductionisabriefoverviewofthelargerproblemaddressedbythecase.Theoverlyingmessageofthesectionis,“Xisimportanttounderstandbecause…”Forexample:

“Smallcellcarcinomaoftheprostateisextremelyrare.Whenitdoesoccur,itisusuallyinconcordancewithprostaticadenocarcinoma…Becausethisconditionisrare,nostandardtreatmentregimenhasbeenestablished…”1.IntroductionAftertheproblemisdescribed,manyauthorsclosetheintroductionsectionbydescribinginonesentencethepatientwhorepresentsthecase.“Thiscasereportdescribesclinicalcharacteristicsofa67-yearoldmanwithsmallcarcinomaoftheprostate.”Thiscreatesasmoothtransitiontothenextsection,TheCase.AftertheproblemisdescribedSpecialLanguageStructuresDefininganillness/term,orpresentingtheconcernedissue…is…·Smallcellcarcinomaoftheprostateisextremelyrare.·Acuteangleclosureglaucomaisagreatmimicoftheotherocular,neurologicalandgastrointestinalcondition.2.…is…,but/however…·Nasalbleedingisacommonillness,butsimpleanalysisindicatesthatpatientswithhematopathywhoalsosuffernasalbleedingaccountsfor5.1%oftotalnasalbleedingcases.SpecialLanguageStructuresDefSpecialLanguageStructuresPresentingthecase(s)withpeculiarities

1.wereport/presentonepatientwith…Wereportonecaseof…·wepresenttwochildrenpatientswithgonorrheawhoweremisdiagnosedasotherdiseases.2.…isnotfullyunderstood/…remainscontroversial·Thepathogenicmechanismofaplasticdiseaseisnotfullyunderstood.·Themechanismofangleclosureglaucomaremainscontroversial.SpecialLanguageStructuresPre2.ThecaseAsinacasepresentation,firstdescribetheperson,thenprovideahistoryofthepresentingcondition.Next,revealtheresultsofthephysicalexamandrelevanttests,anddescribethetreatment.Finally,describetheexpectedoutcomeofthetreatmentplanandcontrastittotheactualoutcome,whensomethingunusualoccurs.2.Thecase2.Thecase(cont)DescriptionofthepatientHistoryofpresentingconditionPhysicalexamandtestsDiagnosis&treatmentActualoutcome2.Thecase(cont)1.Awoman/managed…wasadmittedwith…/for…A(age)patientwith…wasseen/admitted/presentedoneself/cameto…·Lateoneafternoon,a31-year-oldgrocerydeliverydriverpresentedhimselftotheemergencydepartmentcomplainingofleft-sidedchestpain.2.Thepatientcomplainedof/described…·Thepatientcomplainedofsomedifficultyurinating,buturineoutputwasquitegood.1.Awoman/managed…wasadmittHistory:Presentsincemorning,thepatient’spainradiatedtohisleftjawanddownhisleftarm.Thepainincreasedwithdeeprespirationorstrenuousactivity.Hewassweatyanddizzy.Hecomplainedofacoughwithbloodysputum.Thispatientdidalotofheavylifting,upto100poundsatatime.Hefirstnotedpainwhengettingintohistruckafteradelivery.History:Presentsincemorning1.…were/appeared/showed/revealed(ab)normal/,(but…)·Therightrenalarteryandbrancharteriesappearednormalwithoutevidenceofocclusionorstenosisfromintrinsicvasculardisease.2.Noabnormalitywasfoundon…3.…displayed/showed/revealed4.…was/were(not)detected/noted.·Aboutoneweekpriortothisadmission,achestX-raydemonstratedthatmorefluidpresentedthanbeforewasnoted.

1.…were/appeared/showed/revea1.…wasdiagnosedashaving/suffering……wasgiventhediagnosisof…·Atthattime,hewasdiagnosedashavingdiabetesmellitusandhypertension.2.Thepatientwasbegun/startedon…(medicineorprocedure)

·Forthisreason,hewasbegunondigitalisandfluidrestrictionswereinstituted.3.…wasperformed/given/adopted…wassubjectedto…

(atreatment/operation,etc.)

·OnApril30,arightandleftheartcatheterizationfromarightaxillaryveincutdownwasperformed.1.…wasdiagnosedashaving/sActualoutcome:Thepainrecurred,thepatientwenttotheERthentheICU,thecardiactestswerenormal.ThenthoracicradiographsandMRIweredone,revealingdiskbulgesintheneck.Anorthopedicsurgeonperformedanarthroscopic,micro-discectomyattheC6-7level,ontheleft.Thepainresolved.

Actualoutcome:Thepainrecur3.Discussion

Thediscussionisthemostimportantsection!Inthissection,theauthormayfirstreviewtheliterature,andthendiscusseshowtheexistingliteraturerelatestotheindividualcase.Wasthereamismatchinwhatisknownabouttheconditionanditsparticularpresentationinthiscase?Ifthisisastoryaboutsurpriseorpuzzlement,therevelationprocesscanbedescribedhere.Ifexistinghypothesesabouttheconditiondidnotfitthecase,theauthormightproposeanewhypothesis.

Conclusionisnotalwaysnecessaryinacasereportbutifitis,summariesthemessageinafewsentences.3.Discussion

1.Inconclusion/Tosumup/Therefore…

·Inconclusion,liverfunctionshouldbeassessedinanypatientwithunexplainedacutepainsinliverarea.2.Onelessonofthiscaseis