CaseReport病例报告的书写课件.ppt

Case Report Writing8/12/20241CaseReport病例报告的书写Writing: Case reportwA case report is a detailed report of the symptoms, signs, diagnosis, treatment and follow-up of one or two individual patients. It usually describe an unusual or novel occurrence.8/12/20242CaseReport病例报告的书写Writing: Case reportwCase reports permit discovery of new diseases and unexpected effects (adverse or beneficial) as well as the study of mechanisms, and they play an important role in medical education. Case reports and series have a high sensitivity for detecting novelty and therefore remain one of the cornerstones of medical progress; they provide many new ideas in medicine. (Vandenbroucke, 2001) 8/12/20243CaseReport病例报告的书写Writing: Case reportFamous scientific case reports wThe discovery of AIDS in Los Angeles in 1981wSigmund Freud reported on numerous cases, including Anna O., Dora, Little Hans, Rat man, and Wolf man wPaul Broca reported on language impairment following left hemisphere lesions in the 1860s wThe discovery of congenital malformation of neonatals caused by ingestion of thalidomide by the mothers of these babies8/12/20244CaseReport病例报告的书写Writing: Case reportTypes of case reports Most case reports are on one of six topics: 1) An unexpected association between diseases or symptoms. 2) An unexpected event in the course of 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. 6)A positional or quantitative variation of the anatomical structures. 8/12/20245CaseReport病例报告的书写Writing: Case reportStages in writing a case report wFinding a rare casewLiterature searchwCollecting information related to the case, including consent from the patientwRevising and editing8/12/20246CaseReport病例报告的书写Writing: Case reportwStructure of a case report:1.Introduction 2.Case Presentation3.Discussion4.References8/12/20247CaseReport病例报告的书写1. IntroductionThe introduction is a brief overview of the larger problemaddressed by the case. The overlying message of the section is, “ X is important to understand because…” For example: “ Small cell carcinoma of the prostate is extremely rare. When it does occur, it is usually in concordance with prostatic adenocarcinoma… Because this condition is rare, no standard treatment regimen has been established …” 8/12/20248CaseReport病例报告的书写After the problem is described, many authors close the introduction section by describing in one sentence the patient who represents the case.“ This case report describes clinical characteristics of a 67-year old man with smallcarcinoma of the prostate.”This creates a smooth transition to the next section, The Case.8/12/20249CaseReport病例报告的书写Special Language StructureswDefining an illness/term, or presenting the concerned issue1.…is…·Small cell carcinoma of the prostate is extremely rare.·Acute angle closure glaucoma is a great mimic of the other ocular, neurological and gastrointestinal condition. 2. …is…, but/however …·Nasal bleeding is a common illness, but simple analysis indicates that patients with hematopathy who also suffer nasal bleeding accounts for 5.1% of total nasal bleeding cases.8/12/202410CaseReport病例报告的书写Special Language StructureswPresenting the case(s) with peculiarities 1. we report/present one patient with… We report one case of… · we present two children patients with gonorrhea who were misdiagnosed as other diseases.2. …is not fully understood/…remains controversial ·The pathogenic mechanism of aplastic disease is not fully understood. ·The mechanism of angle closure glaucoma remains controversial.8/12/202411CaseReport病例报告的书写2. The caseAs in a case presentation, first describe the person, then provide a history of the presenting condition. Next, reveal the results of the physical exam and relevant tests, and describe the treatment. Finally, describe the expected outcome of the treatment plan and contrast it to the actual outcome, when something unusual occurs.8/12/202412CaseReport病例报告的书写2. The case (cont)wDescription of the patientwHistory of presenting conditionwPhysical exam and testswDiagnosis & treatmentwActual outcome8/12/202413CaseReport病例报告的书写1. A woman/man aged…was admitted with…/for… A (age) patient with…was seen/admitted/ presented oneself/came to… · Late one afternoon, a 31-year-old grocery delivery driver presented himself to the emergency department complaining of left-sided chest pain.2. The patient complained of/described… · The patient complained of some difficulty urinating, but urine output was quite good.8/12/202414CaseReport病例报告的书写wHistory: Present since morning, the patient’s pain radiated to his left jaw and down his left arm. The pain increased with deep respiration or strenuous activity. He was sweaty and dizzy. He complained of a cough with bloody sputum. This patient did a lot of heavy lifting, up to 100 pounds at a time. He first noted pain when getting into his truck after a delivery.8/12/202415CaseReport病例报告的书写1. …were/appeared/showed/revealed (ab)normal/ , (but…) ·The right renal artery and branch arteries appeared normal without evidence of occlusion or stenosis from intrinsic vascular disease.2. No abnormality was found on…3. …displayed/showed/revealed 4. …was/were (not) detected/noted. ·About one week prior to this admission, a chest X-ray demonstrated that more fluid presented than before was noted. 8/12/202416CaseReport病例报告的书写1. …was diagnosed as having /suffering… …was given the diagnosis of… · At that time, he was diagnosed as having diabetes mellitus and hypertension.2. The patient was begun/started on … (medicine or procedure) · For this reason, he was begun on digitalis and fluid restrictions were instituted.3. …was performed/given/adopted … was subjected to … ( a treatment/operation, etc.) · On April 30, a right and left heart catheterization from a right axillary vein cutdown was performed.8/12/202417CaseReport病例报告的书写wActual outcome: The pain recurred, the patient went to the ER then the ICU, the cardiac tests were normal. Then thoracic radiographs and MRI were done, revealing disk bulges in the neck. An orthopedic surgeon performed an arthroscopic, micro-discectomy at the C6-7 level, on the left. The pain resolved. 8/12/202418CaseReport病例报告的书写 3. Discussion The discussion is the most important section ! In this section, the author may first review the literature, and then discusses how the existing literature relates to the individual case. Was there a mismatch in what is known about the condition and its particular presentation in this case? If this is a story about surprise or puzzlement, the revelation process can be described here. If existing hypotheses about the condition did not fit the case, the author might propose a new hypothesis. Conclusion is not always necessary in a case report but if it is ,summaries the message in a few sentences.8/12/202419CaseReport病例报告的书写 1. In conclusion/ To sum up/ Therefore … · In conclusion, liver function should be assessed in any patient with unexplained acute pains in liver area. 2. One lesson of this case is … · One lesson of this case is the need for a detailed history before intervention. 3. …may give rise to … · Pressure effects may give rise to jaundice, cholangitis, acute and recurrent pancreatitis and rarely duodenal obstruction. 8/12/202420CaseReport病例报告的书写4. ReferencesThe reference section is boring and time consuming but extremely important. Keep to the style that your journal requires. 8/12/202421CaseReport病例报告的书写Additional Reading Materials Read the following case reports as the additional reading materials.wA 39-Year-Old Man with Chest Pain, Arthralgias, and a Mediastinal MasswCase Report: Paraarticular Soft-Tissue Osteoma of the Hip wInfitrating Myoepithelial Carcinoma of the Breast, a case report and cytologic-histologic Correlation 8/12/202422CaseReport病例报告的书写8/12/202423CaseReport病例报告的书写。