Case reports represent the oldest and most familiar form of medical communication. Far from a "second-class" publication, many original observations are first presented as case reports. Like scientific abstracts, the case report abstract is governed by rules that dictate its format and length. This article will outline the features of a well-written case report abstract and provide an example to emphasize the main features.
Scientific forums have specific rules regarding how the abstract should appear. For ACP, the rules are available on the electronic abstracts portal. Organizers of scientific meetings set explicit limits on the length of abstracts.
The most difficult decision to make is whether your case report is worth submitting as an abstract. Of course, rarity of a condition almost always meets the criterion of worthiness, but few of us have the opportunity to describe something that is completely new. Another reason to report a case is the lesson that it teaches. With this in mind, consider presenting a case if it increases awareness of a condition, suggests the proper diagnostic strategy, or demonstrates a more cost-effective approach to management. Alternatively, a case can be presented because it represents an unusual presentation of a relatively common condition. Other twists include an unusual complication of a disease and its management. Again, it's important to think about the message or lesson that the case can deliver.
Before you begin writing the abstract, present a quick summary of your case to colleagues or mentors to determine if they agree that the case is worthy of presentation. It is important to contribute something unique, but not if it depends on some trivial variation from previously presented cases. For example, if it is known that a certain cancer widely metastasizes, it is not worthwhile to report each new site. Similarly, drug reactions often merit a case report, but not if it is simply a report of a drug in a class whose other members are known to cause the same reaction.
Once you have decided to submit a case report abstract, describe it in such a way as to make it interesting, yet conform to the accepted format. The following paragraphs provide suggestions on both style and format.
Title and Author Information: The title is a summary of the abstract itself and should convince the reader that the topic is important, relevant, and innovative. However, don't tell everything about the case in the title, otherwise the reader's interest might lag. Make the title short, descriptive, and interesting. Some organizations require a special format for the title, such as all uppercase letters. Be sure to check the instructions. Following the title, include the names of authors followed by their institutional affiliations. Deciding upon the authorship of a case report can be tricky. In the past, it was acceptable to include as authors those contributing to the management of the patient, but this is no longer true. Currently, it is expected that the authors contribute significantly to the intellectual content of the case report. It is assumed that the first author will present the work if the abstract is accepted. The first author may need to meet certain eligibility requirements in order to present the abstract, for example, be a member of the professional society sponsoring the research meeting. This information is always included with the abstract instructions.
Introduction: Most case report abstracts begin with a short introduction. This typically describes the context of the case and explains its relevance and importance. However, it is perfectly acceptable to begin directly with the description of the case.
Case Description: When reporting the case, follow the basic rules of medical communication; describe in sequence the history, physical examination, investigative studies, and the patient's progress and outcome. The trick is to be complete without obscuring the essence of the case with irrelevant details.
Discussion: The main purpose of the discussion is to review why decisions were made and extract the lesson from the case. Not uncommonly, reports from the literature, or their absence, are cited that either directly support or contradict the findings of the case. Be wary of boasting that your case is the "first" to describe a particular phenomenon, since even the most thorough searches often fail to reveal all instances of similar cases. Keep in mind that the best case report abstracts are those that make a small number of teaching points (even just one) in clear and succinct language.
When writing the abstract, avoid the use of medical jargon and excessive reliance on abbreviations. Limit abbreviations to no more than three, and favor commonly used abbreviations. Always spell out the abbreviations the first time they are mentioned unless they are commonly recognized (e.g., CBC).
It typically takes several days to write a good abstract, and the process should not be undertaken alone. Get help from a mentor who is not familiar with the case; such mentors can quickly point out areas that are unclear or demand more detail. Make revisions based upon the feedback. Finally, have others read your draft in order to check for technical errors, such as spelling and grammar mistakes. Reading the abstract out loud is another good way to catch awkward phrasing and word omissions. Finally, a Clinical Vignette Abstract Checklist and an example of a clinical vignette abstract are available to help you with the process of writing a successful abstract.
The most difficult thing with writing a medical case study is to decide what it should contain, and how detailed it should be. Should you include all the symptoms, or only those on which your diagnosis is based? Do you need to describe a daily progress or not?
Though you should try not to omit any important details, your medical case study doesn’t need to include everything. So the general advice is to leave not relevant information aside.
Fortunately, medical case studies follow the same format. And if you stick to it, you can be sure your case study includes everything needed. Read on to discover more about the medicalcase study format and what your case study should contain.
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Medical Case Study Format
This is a typical medical case study outline:
1. Abstract:: This section should include the same sections as the main text, just in succinct form.
2.Introduction: This section should attract the attention and interest of the reader, providing the subject, purpose, and merit of the case study.
3. Case Presentation / Case Report:: This is a very central section. Anyone reading this section should be able to form their own conclusions from this section alone.
4. Management and Treatment: In this section, the plan for care, treatment used, and the outcome are discussed.
5. Discussion: Being the final section, discussion is the most important section of the study. It should evaluate the case, comparing and contrasting it with published literature. It should also summarize the features of the study, justifying why the case is unique, and draw recommendations and conclusions.
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What Should You Include In Case Report?
The case report is the part of the medical case study where you introduce the raw data, medical history, and the results of any examinations that have been performed. The working diagnosis and management of the case are described in the case report as well.
Patient demographics – The demographics of the patient, including age, weight, height, sex, race, and occupation are to be included. Noting the patient’s race and occupation may appear as superfluous; however, this information may uncover pharmacogenomic or environmental factors.
Patient History – This section contains the complaint that brought the patient to seek your care. It is often very useful to use the patient’s own words. Next, you introduce the information obtained for compiling the history of the patient. It is not necessary to include every detail, just the relevant information that helped you to determine a diagnosis.
Clinical Examination – In this section, the diagnostic procedures and the timeline in which they were administered should be addressed. As in the previous section, every detail is not needed, just the information that was relevant to diagnosing the patient.
Differential Diagnosis – This section of the case report is a short list of the most likely diseases and/or disorders from the patient’s symptoms. This section is usually a result of the patient history section of the case report.
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What to Include in Management and Treatment section of Medical Case Study?
In this section of the clinical case study, you should clearly describe the plan for caring for the patient, as well as the care that was actually provided, and the resulting outcome.
You should be as specific as possible when describing the treatment used. In this section you should avoid the daily progress of the patient, including normal vital signs and other information that is not relevant.
Indicate the effect of any and all treatment, any unanticipated effects, the patient’s final outcome, any further proposed treatments, and the patient’s status at the time of the report.
You may want to include the patient’s own account of their improvement or lack thereof. But whenever possible, use a well-validated method of measuring their improvement.
For your medical case study, it may be possible to use data from visual analog scales for pain, or a medication usage journal.
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What Is Discussion Section Of Medical Case Study For?
The discussion section is used to synthesize the foregoing sections and explain the correlations as well as the apparent inconsistencies. This section should also include a detailed explanation of the literature review. If appropriate, using just a few sentences, describe any lesson to be learned from the medical case study.
You should take care not to make firm judgments or sweeping recommendations based upon speculation, limited and tenuous information, or on a few case reports. Only justifiable evidence-based recommendations should be noted.
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Types of Medical Case Studies
There are two types of medical case studies that you may come across during your education. The first only provides you the patient’s medical history and initial diagnosis. Based on the information contained within, you will be required to justify the diagnosis and provide recommendations for treatment.
The second type of case study describes the situation at hand and includes the chosen solution and furthermore, the outcome of said solution. With this type of case study, you will be required to determine how and why the solution succeeded or failed.
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