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Writing a Case Report: Introduction

What is a Case Report

A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine. Some reports contain an extensive review of the relevant literature on the topic. The case report is a rapid short communication between busy clinicians who may not have time or resources to conduct large scale research.

Components of your Case Report

Different journals may have different formats or variations for case reports, so you should look at other case reports published in the journal you are submitting to; the journal may also have detailed instrutions on their site.

If you are writing a case report for the Case Management class, use the following format for your paper:
 

Make sure to include the words case report in your title

  • AOM literature review
  • Biomedicine literature review: The next part of your paper will be a Background section. Find a Western research article that is related to the patient’s chief complaint, (You could also research their medications or a surgery, a genetic condition, etc.) and one from a TCM perspective relating to the any aspect of your diagnosis or treatment. Briefly summarize and include your findings in the background area of your paper. Find research that is meaningful to your paper. You will use superscript and cite your research in AMA format in the end of your paper in a area titled “references or citations”.

Don't know what a Literature Review is? Watch the "Get Lit" video for a better understanding of what this section should look like.

  • Age, gender, and occupation
  • Total number of treatments and how many treatments have been provided by you
  • Chief complaint(s)
    • Date of onset and causes
    • OPQRST and associated symptoms
    • Previous AOM treatments and results
    • Relevant “Ten Questions”
  • Western Medical diagnosis and treatments
    • Surgeries
    • Relevant health history
    • Medications, and why they are taking the medications. Include dosages
    • Relevant Family history
    • Lifestyle details: diet, exercise, history of smoking or drug u
  • Brief physical description
  • Vital signs (BP, HR, height, weight)
  • Tongue, pulse, finding from palpation
  • Other supplemental data
  • Range of Motion
  • Orthopedic tests
  • MYMOPS, VAS, etc
  • Use a specific OAT appropriate to the patient’s chief complaint
  • Working diagnosis and pattern
    • TCM disease diagnosis (bian bing)
    • TCM Pattern differentiation (bian zheng)
    • Validating signs and symptoms (no chart this time)
    • Explanation of contradictory signs and symptoms. Distinction between root and branch diagnoses if necessary
  • Treatment principles (based on diagnosis)
  • Treatment method (e.g. acupuncture, moxa, etc.)
  • Points prescription with needle stimulation method.(e.g. Warm needle on ST 36, Lifting, and thrusting on GB 20 until muscle fasciculated, even technique on PC 6. You can use symbols + tonifying, - reducing, = even.)
  • Herbal prescriptions/formulas with dosages (e.g. Xiao Yao Wan tea pills, 8 pills TID.)
  • Patient education and recommendations or referrals
  • Treatment plan
  • Focus of treatment
  • Short and long term goals
  • Outcome measurement changes (compare the change between the first time you used your outcome measurement tool and the last time)
  • Compliancy with herbs
  • Frequency of treatment maintained
  • Closing discussion
  • Cite your research articles in AMA format

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