CaseReport病例报告的书写

CaseReportWriting8/23/20231Writing:CasereportAcasereportisadetailedreportofthesymptoms,signs,diagnosis,treatmentandfollow-upofoneortwoindividualpatients.Itusuallydescribeanunusualornoveloccurrence.8/23/20232Writing:CasereportCasereportspermitdiscoveryofnewdiseasesandunexpectedeffects(adverseorbeneficial)aswellasthestudyofmechanisms,andtheyplayanimportantroleinmedicaleducation.Casereportsandserieshaveahighsensitivityfordetectingnoveltyandthereforeremainoneofthecornerstonesofmedicalprogress;theyprovidemanynewideasinmedicine.(Vandenbroucke,2001)8/23/20233Writing:CasereportFamousscientificcasereports

ThediscoveryofAIDSinLosAngelesin1981SigmundFreudreportedonnumerouscases,includingAnnaO.,Dora,LittleHans,Ratman,andWolfmanPaulBrocareportedonlanguageimpairmentfollowinglefthemispherelesionsinthe1860sThediscoveryofcongenitalmalformationofneonatalscausedbyingestionofthalidomidebythemothersofthesebabies8/23/20234Writing:CasereportTypesofcasereportsMostcasereportsareononeofsixtopics:1)Anunexpectedassociationbetweendiseasesorsymptoms.2)Anunexpectedeventinthecourseofobservingortreatingapatient.3)Findingsthatshednewlightonthepossiblepathogenesisofadiseaseoranadverseeffect.4)Uniqueorrarefeaturesofadisease.5)Uniquetherapeuticapproaches.6)Apositionalorquantitativevariationoftheanatomicalstructures.8/23/20235Writing:CasereportStagesinwritingacasereport

FindingararecaseLiteraturesearchCollectinginformationrelatedtothecase,includingconsentfromthepatientRevisingandediting8/23/20236Writing:CasereportStructureofacasereport:IntroductionCasePresentationDiscussionReferences8/23/202371.IntroductionTheintroductionisabriefoverviewofthelargerproblemaddressedbythecase.Theoverlyingmessageofthesectionis,“Xisimportanttounderstandbecause…〞Forexample:

“Smallcellcarcinomaoftheprostateisextremelyrare.Whenitdoesoccur,itisusuallyinconcordancewithprostaticadenocarcinoma…Becausethisconditionisrare,nostandardtreatmentregimenhasbeenestablished…〞8/23/20238Aftertheproblemisdescribed,manyauthorsclosetheintroductionsectionbydescribinginonesentencethepatientwhorepresentsthecase.“Thiscasereportdescribesclinicalcharacteristicsofa67-yearoldmanwithsmallcarcinomaoftheprostate.〞Thiscreatesasmoothtransitiontothenextsection,TheCase.8/23/20239SpecialLanguageStructuresDefininganillness/term,orpresentingtheconcernedissue…is…·Smallcellcarcinomaoftheprostateisextremelyrare.·Acuteangleclosureglaucomaisagreatmimicoftheotherocular,neurologicalandgastrointestinalcondition.2.…is…,but/however…·Nasalbleedingisacommonillness,butsimpleanalysisindicatesthatpatientswithhematopathywhoalsosuffernasalbleedingaccountsfor5.1%oftotalnasalbleedingcases.8/23/202310SpecialLanguageStructuresPresentingthecase(s)withpeculiarities

1.wereport/presentonepatientwith…Wereportonecaseof…

·wepresenttwochildrenpatientswithgonorrheawhoweremisdiagnosedasotherdiseases.2.…isnotfullyunderstood/…remainscontroversial

·Thepathogenicmechanismofaplasticdiseaseisnotfullyunderstood.

·Themechanismofangleclosureglaucomaremainscontroversial.8/23/2023112.ThecaseAsinacasepresentation,firstdescribetheperson,thenprovideahistoryofthepresentingcondition.Next,revealtheresultsofthephysicalexamandrelevanttests,anddescribethetreatment.Finally,describetheexpectedoutcomeofthetreatmentplanandcontrastittotheactualoutcome,whensomethingunusualoccurs.8/23/2023122.Thecase(cont)DescriptionofthepatientHistoryofpresentingconditionPhysicalexamandtestsDiagnosis&treatmentActualoutcome8/23/2023131.Awoman/managed…wasadmittedwith…/for…A(age)patientwith…wasseen/admitted/presentedoneself/cameto…·Lateoneafternoon,a31-year-oldgrocerydeliverydriverpresentedhimselftotheemergencydepartmentcomplainingofleft-sidedchestpain.2.Thepatientcomplainedof/described…·Thepatientcomplainedofsomedifficultyurinating,buturineoutputwasquitegood.8/23/202314History:Presentsincemorning,thepatient’spainradiatedtohisleftjawanddownhisleftarm.Thepainincreasedwithdeeprespirationorstrenuousactivity.Hewassweatyanddizzy.Hecomplainedofacoughwithbloodysputum.Thispatientdidalotofheavylifting,upto100poundsatatime.Hefirstnotedpainwhengettingintohistruckafteradelivery.8/23/2023151.…were/appeared/showed/revealed(ab)normal/,(but…)·Therightrenalarteryandbrancharteriesappearednormalwithoutevidenceofocclusionorstenosisfromintrinsicvasculardisease.2.Noabnormalitywasfoundon…3.…displayed/showed/revealed4.…was/were(not)detected/noted.·Aboutoneweekpriortothisadmission,achestX-raydemonstratedthatmorefluidpresentedthanbeforewasnoted.

8/23/2023161.…wasdiagnosedashaving/suffering……wasgiventhediagnosisof…·Atthattime,hewasdiagnosedashavingdiabetesmellitusandhypertension.2.Thepatientwasbegun/startedon…(medicineorprocedure)

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

(atreatment/operation,etc.)

·OnApril30,arightandleftheartcatheterizationfromarightaxillaryveincutdownwasperformed.8/23/202317Actualoutcome:Thepainrecurred,thepatientwenttotheERthentheICU,thecardiactestswerenormal.ThenthoracicradiographsandMRIweredone,revealingdiskbulgesintheneck.Anorthopedicsurgeonperformedanarthroscopic,micro-discectomyattheC6-7level,ontheleft.Thepainresolved.

8/23/2023183.Discussion

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

Conclusionisnotalwaysnecessaryinacasereportbutifitis,summariesthemessageinafewsentences.8/23/202319

1.Inconclusion/Tosumup/Therefore…

·Inconclusion,liverfunctionshouldbeassessedinanypatientwithunexplainedacutepainsinliverarea.2.Oneless