Again, we should write in an efficient narrative style, restricting ourselves to the relevant information. It is not necessary to include every detail in our clinical notes.
If we are using a named orthopedic or neurological test, it is best to both name and describe the test since some people may know the test by a different name. X-rays or other images are only helpful if they are clear enough to be easily reproduced and if they are accompanied by a legend.
Be sure that any information that might identify a patient is removed before the image is submitted. At this point, or at the beginning of the next section, we will want to present our working diagnosis or clinical impression of the patient.
Management and Outcome: In this section, we should clearly describe the plan for care, as well as the care which was actually provided, and the outcome. It is useful for the reader to know how long the patient was under care and how many times they were treated. Additionally, we should be as specific as possible in describing the treatment that we used.
If we used spinal manipulation, it is best to name the technique, if a common name exists, and also to describe the manipulation. Remember that our case study may be read by people who are not familiar with spinal manipulation, and, even within chiropractic circles, nomenclature for technique is not well standardized. However, whenever possible we should try to use a well-validated method of measuring their improvement.
For case studies, it may be possible to use data from visual analogue scales VAS for pain, or a journal of medication usage. It is useful to include in this section an indication of how and why treatment finished. Did we decide to terminate care, and if so, why? Did the patient withdraw from care or did we refer them to another practitioner? Discussion: In this section we may want to identify any questions that the case raises. It is not our duty to provide a complete physiological explanation for everything that we observed.
This is usually impossible. If there is a well established item of physiology or pathology which illuminates the case, we certainly include it, but remember that we are writing what is primarily a clinical chronicle, not a basic scientific paper. Finally, we summarize the lessons learned from this case. Acknowledgments: If someone provided assistance with the preparation of the case study, we thank them briefly.
It is neither necessary nor conventional to thank the patient although we appreciate what they have taught us. It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper. References: References should be listed as described elsewhere in the instructions to authors.
Only use references that you have read and understood, and actually used to support the case study. Do not use more than approximately 15 references without some clear justification.
Try to avoid using textbooks as references, since it is assumed that most readers would already have this information. Also, do not refer to personal communication, since readers have no way of checking this information. Legends: If we used any tables, figures or photographs, they should be accompanied by a succinct explanation. A good rule for graphs is that they should contain sufficient information to be generally decipherable without reference to a legend. Permissions: If any tables, figures or photographs, or substantial quotations, have been borrowed from other publications, we must include a letter of permission from the publisher.
Also, if we use any photographs which might identify a patient, we will need their written permission. In addition, patient consent to publish the case report is also required. Introductory sentence: e. This 25 year old female office worker presented for the treatment of recurrent headaches. Describe the essential nature of the complaint, including location, intensity and associated symptoms: e. Her headaches are primarily in the suboccipital region, bilaterally but worse on the right.
Sometimes there is radiation towards the right temple. She describes the pain as having an intensity of up to 5 out of ten, accompanied by a feeling of tension in the back of the head. When the pain is particularly bad, she feels that her vision is blurred. Further development of history including details of time and circumstances of onset, and the evolution of the complaint: e. This problem began to develop three years ago when she commenced work as a data entry clerk.
Her headaches have increased in frequency in the past year, now occurring three to four days per week. Describe relieving and aggravating factors, including responses to other treatment: e. The pain seems to be worse towards the end of the work day and is aggravated by stress.
Aspirin provides some relieve. She has not sought any other treatment. Include other health history, if relevant: e. Otherwise the patient reports that she is in good health. Summarize the results of examination, which might include general observation and postural analysis, orthopedic exam, neurological exam and chiropractic examination static and motion palpation : e. Examination revealed an otherwise fit-looking young woman with slight anterior carriage of the head.
Cervical active ranges of motion were full and painless except for some slight restriction of left lateral bending and rotation of the head to the left. These motions were accompanied by discomfort in the right side of the neck. Cervical compression of the neck in the neutral position did not create discomfort. However, compression of the neck in right rotation and extension produced some right suboccipital pain. Cranial nerve examination was normal.
Upper limb motor, sensory and reflex functions were normal. With the patient in the supine position, static palpation revealed tender trigger points bilaterally in the cervical musculature and right trapezius.
Motion palpation revealed restrictions of right and left rotation in the upper cervical spine, and restriction of left lateral bending in the mid to lower cervical spine. There were no carotid bruits. It is in a narrative form. Case studies are the clinical records which will help to list questions for a designed clinical study. These guidelines are planned to assist the novice practitioner or student which helps him to navigate easily in the course of medical case study format.
No personal information about the patient will be mentioned in your report. The patient should be identified by an identification number or dummy name. X-rays or any other images are helpful only if they are clear enough and if they are authentic. In this section, you should design the plan for care, and the care which was provided.
Details like the duration of hospitalization, the treatment already provided and for how much time and the improvements during treatment. Even the details if the treatment was stopped and why are mentioned in the medical coding practice case studies. This is the section, where you can thank all those who supported your research or helped you in writing. You should acknowledge who assisted you and last but not the least the patient. In your medical case study sample report, the bibliographic information is mentioned in the end.
Use the references you have read, understood, and used to support the case study. Try not to list more than 15 references approx. Avoid using textbooks as references, since most readers would already have this information. Use of any tables, figures or photographs should be accompanied by a complete explanation. The graphs should contain all the relevant information. Tables, figures and photographs should be included at the end of the report.
If any photographs, tables, figures, or substantial quotations, have been taken from other publications, a permission letter from the publisher is a must.
General Instructions. Title Page. A good introduction must have. A reason why the topic is important. The historical context of this condition Difficulties faced in diagnosis or treatment The information about treatment and diagnosis. Case Presentation. Privacy policy. When you revise your paper you should: [19] X Research source Provide a letter in which you answer each of the comments provided by each reviewer and provide page numbers showing how you addressed the comments in the manuscript Submit the letter with the revised manuscript If the original journal did not invite you to resubmit, then you can submit the revised version to a different journal and go through a new round of peer review.
Get an acceptance. If you are able to answer all of the reviewers' and editors' comments on the manuscript in a way that is satisfactory, your paper is likely to be accepted after you revise it.
You will receive another decision which will indicate that either: The paper is accepted as it is. The paper is accepted after minor changes. You may receive this decision if the editor is largely satisfied, but has small content corrections or formatting changes that need to be made.
Check the proofs. After your paper is accepted, the journal will send you a draft to look over. These are called the proofs. You should check: That all the tables and figures appear correctly in the right order. That there have been no errors in any mathematical formulas. That the body of the paper is correct and contains no typos or formatting errors.
That the names and affiliations of the authors are correct. Sign any necessary contracts. Read through the contract to make sure you fully understand the copyright implications of the contract. Things to consider are: Do you as the author retain the copyright? Or will it belong to the journal? Are you prohibited from making the article freely available online? Is there an embargo period, meaning that you cannot talk to the press about your results before the journal publishes the paper?
Include your email address to get a message when this question is answered. By using this service, some information may be shared with YouTube. You Might Also Like How to. How to. More References About This Article. Medically reviewed by:. Co-authors: Updated: June 14, Categories: Medical Skills Medical Studies.
Medical Disclaimer The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. Article Summary X To start a medical case study report, first choose a title that clearly reflects the contents of the report.
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