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Case write up medicine

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Obtain informed consent from the patient see " Do I have to obtain informed consent from the patient? Journals may have their own informed consent form that they would like you to use, so please look for this when selecting a journal. Once you've identified the case, selected an appropriate journal s , and considered informed consent, you can collect the required information to write the case report.

Once you identify a case and have learned what information to include in the case report, try to find a previously published case report. Finding published case reports in a similar field will provide examples to guide you through the process of writing a case report. There are numerous other journals where you can find published case reports to help guide you in your writing.

The CARE guidelines recommend obtaining informed consent from patients for all case reports. Our recommendation is to obtain informed consent from the patient. Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports. Please consider this as well. Once you have written a draft of the case report, you should seek feedback on your writing, from experts in the field if possible, or from those who have written case reports before.

Aside from BMJ Case Reports mentioned above, there are many, many journals out there who publish medical case reports. Ask your mentor if they have a journal they would like to use. If you need to select on your own, here are some strategies:. Do a PubMed search. When the results appear, on the left side of the page is a limiter for "article type". Case reports are an article type you can limit your search results to.

If you don't see that option on the left, click "additional filters". Review the case reports that come up, and see what journals they are published in. Check with specialty societies. Many specialty societies are affiliated with one or more journal, which can be reviewed for ones that match your needs. Search through individual publisher journal lists. This is exclusive to Elsevier journals.

Be aware that it may not be free to publish your case report. Many journals charge publication fees. Of note, many open access journals charge author fees of thousands of dollars. Other journals have smaller page charges i. It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish.

CHM does NOT have funds to support publication costs, so this is an important step if you do not want to pay out of pocket for publishing. Glob Adv Health Med. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. Guidelines to writing a clinical case report. Heart Views. The importance of writing and publishing case reports during medical education. Writing and publishing a useful and interesting case report.

BMJ Case Reports. Camm CF. European Heart Jounrnal. Faculty Staff Community Researchers Map. Actions Shares. No notes for slide. Affarizal 1 st write up medicine 1. Effarezan Abdul Rahman 1 P a g e 2. NAME: Mrs. She described the pain as tightness which was so severe until wake her up from her sleep. The pain was preceded by palpitation and cough which she experienced a few hours before sleep but she denied having sputum, shortness of breath, orthopnea, and PND.

Because of that, she take 2 tablet of GTN to relieved it after the first tablet still did not relieved the pain. According to her, the pain did relieved for about 20 minutes, however started to recur again but becomes less severe. Because of that, her husband brought her to Selayang Hospital. There was no history of leg swelling, headache, hemoptysis, nausea, vomiting, fever, difficult or painful swallowing.

She also denied any loss of consciousness, turns to blue or became pale. On further questioning, she had history of multiple hospitalization due to the same complain which were at Selayang Hospital and Selama Hospital,Taiping since According to her, the pain occurring almost every month and she was hospitalized 2 P a g e 3. She was worried because the pain becoming frequent lately and occurs about 2 to 3 times in a month. She had hypertension and hypothyroid since which she discovered when seeking general practioner in Klinik Kesihatan.

She did experienced headache and dizziness because of that. She also had history of hospitalization in IJN for 3 days for pericardial effusion on and complains no complication after that. Ainul Rofidah is the eldest out of 10 siblings. All of her siblings are healthy. Her father had passed away due to stroke at the age of 60 years old and her mother had passed away due to GIT cancer at the age of 59 years old.

She is married with 5 children. All of his children are well and healthy. Ainul Rofidah lives at Taman Sri Gombak with her husband and children in a single storey terrace house with proper water and electrical supply. She is non smoker and not consumes any alcohol. Ainul Rofidah, moderately-built lady was alert and conscious.

She was lying comfortably on the bed. She was not in pain and not in respiratory distress. On examination of her hands, the hand was warm and moist. She was not pale, not jaundice and have no cataract. The hydrational status and dentition were good. There was no oral candidiasis noted. There was no pitting oedema.

On examination of the neck region, there was no palpable lymph node and no enlarged thyroid. Examination of the back revealed no bony tenderness and no sacral oedema. There was no chest deformity, no surgical scar, no dilated superficial vein, no visible pulsation and no skin discolouration. On palpation, the apex beat was located at 5th intercostals space within the left midclavicular line. No heave or thrill noted. On percussion revealed normal cardiac dullness.

There was no murmur. On palpation, the trachea was centrally located, normal chest expansion, and normal vocal fremitus at both upper, middle and lower zone. Apex beat was palpable at the 6th intercostals space at the left midclavicular line.

On percussion, there was normal resonance anterior and posteriorly and normal cardiac and liver dullness were noted On auscultation, vesicular breath sound was heard with normal air entry and normal vocal resonance of both sides. No crepitation and rhonchi noted. There was no obvious swelling. The abdomen moves normally with respiration. On palpation, the abdomen was soft, non- tender, no mass palpable. There was no hepatosplenomegaly. The kidneys were not ballotable.

On percussion, there was no area of dullness and negative shifting dullness. On auscultation, normal bowel sound was heard. Per rectal revealed no abnormality. Normal muscle tone of both upper and lower limbs.

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Oral hygiene was good however his tongue was coated. There was no central cyanosis. The JVP was not raised. No palpable cervical or supraclavicular lymph nodes. Regular rhythm and good volume. On precordium examination, the chest moved symmetrically with respiration. There were no scars, dilated veins, or visible apex beat. The apex beat was palpable at the left 5th ICS, at midclavicular line.

There was no parasternal heave or thrills palpable. On auscultation, normal S1, S2 were heard. No murmur. On chest examination, the chest moved symmetrically with respiration. The shape of the chest was normal. There was no scar or dilated veins. Chest expansion was symmetrical bilaterally. Vocal fremitus was normal. On percussion, the lungs were resonance. On auscultation, there is reduced breath sound with vesicular breath sounds was heard and present of crepitation bibasally.

The vocal resonance was normal and equal bilaterally. Abdominal examination On inspection, the abdomen not distended. The umbilicus was centrally located. There was no scar and no dilated veins. On palpation, the abdomen was soft and non tender. There was no hepatosplenomegaly. There was no shifting dullness and fluid thrill.

Neurological examination. On inspection of upper limb, there was no muscle wasting, abnormal posture, scar and fasciculation. The tone, power and reflex of both upper limbs were normal. The patient did not have intention tremor, past pointing, dysdiadokinesia.

On lower limbs examination, on inspection, there was no wasting, no abnormal posture, no scar and no fasciculation. The tone, power and reflex of both lower limbs were normal. The coordination was intact. Pain sensation was intact and also proprioception. All cranial nerve was intact. Mr Rosli, 51 years old malay man, an active smoker, newly diagnosed Diabetes Mellitus and Hyperlipidemia 2 months ago not on medication presented with sudden non radiating central chest pain compressing in nature occured during rest lasted for more than 30 minutes with no relieving factor associated with palpitation and mild shortness of breath on the day of admission.

On examination, he looks lethargy and tachypnoiec, there is clubbing, and on auscultation of the lung there is reduced breath sound and presence of crepitation bibasally. Aortic Dissection. Result : Red blood cells RBC 5. Impression: There is leucocytosis with predominantly increased in neutrophil. There might be presence of concurrent infection or as evidence of inflammatory response towards acute myocardial damage secondary to myocardial infarction.

Reason: to look for the baseline level whether it is safe to start thrombolytic therapy in case if the patient is indicted for thrombolysis. Cholesterol 6. UREA 5. Reason: to detect any electrolyte imbalance that will precipitate this patient condition such as inducing cardiac arrhythmias and also help in management of this patient.

Reason: to look for signs of heart failure e. Result: the chest xray was taken in postero-anterior view, the exposure and penetration were adequate. There was no cardiomegaly. No pleural line and devoid of cardiac marking and tachea is centrally located. Reason: to look for any regional wall motion abnormality which is one of the complication of myocardial infarction.

In addition, MI can also cause wall aneurysm and mitral regurgitation. Acute coronary syndrome is a condition which share a common underlying pathology in which there will be plaque rupture leading to platelet aggregation and adhesion, localized thrombosis, vasoconstriction and distal thrombus embolization result in myocardial ischemia due to reduction in coronary blood flow. This syndrome includes:. Unstable angina 2. Symptoms: patient may presented with prolonged cardiac pain chest, epigastrium, back , associated with nausea, vomiting, profuse sweating, palpitation, anxiety, restlessness and they can even collapse.

However, atypical presentation can occur in elderly, women and in diabetics. Signs: from the physical examination there may be pallor, sweating, irregular pulse, hypotension, and fourth heart sound. It is also crucial to determine the risk factors that predisposed patient to acute coronary syndrome to help in the diagnosis and also for an effective management of patient with ACS.

The risk factors can be divided into 2 which are:. Modifiable factors: Smoking, hypertension, diabetes mellitus, hyperlipidemia, obesity and sedentary lifestyle. The other cardiac biomarkers that are available and of higher diagnostic value but not done in this patient are:. However, it must be remembered that too early measurement sometimes can misleading to low level of serum cardiac biomarkers since each of it has its own duration when it begin to rise and became peak, therefore serial cardiac biomarkers may be needed in patient suspected to have ACS.

Generally, the length of hospitalization for uncomplicated cases is days. Patients should initially be kept at bed rest. Within 24 hours after admission, patients with uncomplicated course should begin sitting on a chair, use a bedside commode, and should be encouraged to help themselves to shave, and eat. Patients should be encouraged to begin walking in the room on the third day after admission and should be fully ambulatory by days.

In this case, patient might be able to resume his work weeks after discharge, as his work is not that strenuous. Driving can be resumed after about weeks. Regular aerobic exercise is recommended for those who had uncomplicated course of MI. Open navigation menu. Close suggestions Search Search.

User Settings. Skip carousel. Carousel Previous. Carousel Next. What is Scribd? Internal Medicine Case Write Up 1. Uploaded by Shafiah Aqilah Mohd Jamal. Document Information click to expand document information Original Title internal-medicine-case-write-up Did you find this document useful? Is this content inappropriate? Report this Document. Flag for inappropriate content. Download now. Save Save internal-medicine-case-write-up Original Title: internal-medicine-case-write-up Related titles.

Carousel Previous Carousel Next. Jump to Page. Search inside document. Systemic Reviews: General: There was no fever, loss of appetite, or loss of weight. Respiratory system: There was no cough, sputum, hemoptysis, night sweat, wheeze, or sore throat. Hematological system: No purpura, epistaxis, or gum bleeding. Musculo-skeletal system: No muscle cramp, joint pain, joint swelling, or stiffness.

Skin: No rash, ulcer, or pruritus. The first paragraph had just grabbed you and you could not put it down. E very patient has an interesting story to tell. The most successful write-ups are those that tell the story rather than report a list of facts. Comment on the source of the information and its reliability in the CC or HPI , if it is not obvious.

If the patient truly is a poor historian, you should provide a brief explanation of why e. J could walk a mile one month ago without getting dyspneic, but over the past month his DOE gradually progressed to the point that he cannot walk 50 feet without stopping to catch his breath. Pertinent positives and negatives i. Also, it shows you care and will engender trust. For patients who already have those sections populated with data, it is efficient to update and correct this data rather than repeat it all in the note.

In your note you can include only what is relevant to the current admission or visit in an outpatient setting. Past history is notable for 1. HTN 2. This requires a much higher skill level than just dumping everything in the note. Are you up to the challenge? Vital signs Other than temperature, you should confirm the vital signs yourself. They are vital. Orthostatics or other special maneuvers like pulsus paradoxus are included with the vitals. General description of the patient. Try to provide a description that would allow your attending to go from room-to-room and identify your patient.

The remainder of the physical exam follows the pattern of inspection, palpation, percussion, and auscultation as appropriate. The physical exam traditionally is presented in head to toe order with neuro coming last.

Refer to Bates. Do not include old lab data in this section e. ECHO from 3 years ago. This requires a higher level of clinical reasoning and fund of knowledge, but give it a try. This is the place where you commit to a diagnosis, provide insight into your reasons, and discuss the relevant differential.

Many physicians like to provide an overview in a couple of sentences so someone can quickly see their assessment, called a summary statement. This is usually formatted with patient demographics, followed by chief concern, then very select findings that support your to the leading diagnosis. Jones is a 45 year-old man with alcohol abuse presenting with epigastric pain and an elevated lipase most consistent with alcohol-induced pancreatitis.

You would then follow this summary statement with a brief paragraph addressing any findings that might point you away from your leading diagnosis and other diagnoses you are considering and why the differential diagnosis. The more certain you are of your leading diagnosis, the shorter this discussion will be. Conversely, many times you will not be certain of the leading diagnosis.

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There is also no orthopnea, PND, reduced effort tolerance, leg swelling. No history of trauma to the chest prior to onset, no underlying lung disease, similar problem before. No recent history of surgery, long distance travelling or lower limb fracture. Systemic Reviews:. Cardiovascular system: Other than chest pain, palpitation, and dyspnea, there was no orthopnea, paroxysmal nocturnal dyspnea, or decreased effort tolerance.

Gastro-intestinal system: There was no nausea, vomiting, abdominal pain, diarrhea, constipation, hematemesis, or malaena. Genito-urinary system: Other than polyuria and nocturia, there was no frequency, dysuria, hematuria, hesitancy, loin pain, or discharge. Neurological system: No loss of consciousness, headache, weakness, numbness, seizures, or poor vision. He was newly diagnosed with Diabetes Mellitus and Hyperlipidemia 2 months ago during routine medical check-up at his workplace.

On further questioning, he actually already had polydipsia, polyuria and nocturia times wakeup in the night since about 4 months prior to that but never seek any medical attention. Then, he was given oral hypoglycemic agent and anti hyperlipidemia but never took the medication and only did some diet change such as reduce intake of carbohydrate and food and drink containing sugar.

However, no other medical illnesses such as hypertension, asthma and etc. No previous history of hospitalization. He is not on any medication and no known allergy to drug and food. He not taking any traditional medication. No history of premature death and malignancy in the family. No other medical illness in other siblings. He married to his wife since 27 years ago and gifted with 4 children.

Currently he stayed with her wife and his 3 children at Balok in a single storey house. His house is equipped with electricity, pipe water supply, and flush toilet. He works as technician worker at factory and his wife work as tailor. The household monthly income is about rm He is an active smoker with 25 pack years. He did not consume alcohol, involve in illicit drug use, or had any sexual promiscuity. He did not active in sports. On general inspection, my patient a medium built Malay man was conscious and alert.

Hydration status was good with capillary refill time of less than two seconds. On examination of the hand, the palm was warm and not clammy in room temperature. There was mild clubbing. There was no collapsing pulse, radio-radial delay, or radio-femoral delay. There was multiple bruises over bilateral cubital fossa which may be due to intravenous line insertion previously.

On examination of the face, he was not pale or jaundice. Oral hygiene was good however his tongue was coated. There was no central cyanosis. The JVP was not raised. No palpable cervical or supraclavicular lymph nodes. Regular rhythm and good volume. On precordium examination, the chest moved symmetrically with respiration.

There were no scars, dilated veins, or visible apex beat. The apex beat was palpable at the left 5th ICS, at midclavicular line. There was no parasternal heave or thrills palpable. On auscultation, normal S1, S2 were heard. No murmur. On chest examination, the chest moved symmetrically with respiration. The shape of the chest was normal. There was no scar or dilated veins. Chest expansion was symmetrical bilaterally. Vocal fremitus was normal. On percussion, the lungs were resonance.

On auscultation, there is reduced breath sound with vesicular breath sounds was heard and present of crepitation bibasally. The vocal resonance was normal and equal bilaterally. Abdominal examination On inspection, the abdomen not distended. The umbilicus was centrally located. There was no scar and no dilated veins. On palpation, the abdomen was soft and non tender. There was no hepatosplenomegaly. There was no shifting dullness and fluid thrill.

Neurological examination. On inspection of upper limb, there was no muscle wasting, abnormal posture, scar and fasciculation. The tone, power and reflex of both upper limbs were normal. The patient did not have intention tremor, past pointing, dysdiadokinesia. On lower limbs examination, on inspection, there was no wasting, no abnormal posture, no scar and no fasciculation.

The tone, power and reflex of both lower limbs were normal. The coordination was intact. Pain sensation was intact and also proprioception. All cranial nerve was intact. Mr Rosli, 51 years old malay man, an active smoker, newly diagnosed Diabetes Mellitus and Hyperlipidemia 2 months ago not on medication presented with sudden non radiating central chest pain compressing in nature occured during rest lasted for more than 30 minutes with no relieving factor associated with palpitation and mild shortness of breath on the day of admission.

On examination, he looks lethargy and tachypnoiec, there is clubbing, and on auscultation of the lung there is reduced breath sound and presence of crepitation bibasally. Aortic Dissection. Result : Red blood cells RBC 5.

Impression: There is leucocytosis with predominantly increased in neutrophil. There might be presence of concurrent infection or as evidence of inflammatory response towards acute myocardial damage secondary to myocardial infarction.

Reason: to look for the baseline level whether it is safe to start thrombolytic therapy in case if the patient is indicted for thrombolysis. Cholesterol 6. UREA 5. Reason: to detect any electrolyte imbalance that will precipitate this patient condition such as inducing cardiac arrhythmias and also help in management of this patient. Reason: to look for signs of heart failure e. Result: the chest xray was taken in postero-anterior view, the exposure and penetration were adequate.

There was no cardiomegaly. No pleural line and devoid of cardiac marking and tachea is centrally located. Reason: to look for any regional wall motion abnormality which is one of the complication of myocardial infarction. In addition, MI can also cause wall aneurysm and mitral regurgitation. Acute coronary syndrome is a condition which share a common underlying pathology in which there will be plaque rupture leading to platelet aggregation and adhesion, localized thrombosis, vasoconstriction and distal thrombus embolization result in myocardial ischemia due to reduction in coronary blood flow.

This syndrome includes:. Unstable angina 2. Symptoms: patient may presented with prolonged cardiac pain chest, epigastrium, back , associated with nausea, vomiting, profuse sweating, palpitation, anxiety, restlessness and they can even collapse. However, atypical presentation can occur in elderly, women and in diabetics. Signs: from the physical examination there may be pallor, sweating, irregular pulse, hypotension, and fourth heart sound.

It is also crucial to determine the risk factors that predisposed patient to acute coronary syndrome to help in the diagnosis and also for an effective management of patient with ACS. The risk factors can be divided into 2 which are:. Modifiable factors: Smoking, hypertension, diabetes mellitus, hyperlipidemia, obesity and sedentary lifestyle. The other cardiac biomarkers that are available and of higher diagnostic value but not done in this patient are:.

However, it must be remembered that too early measurement sometimes can misleading to low level of serum cardiac biomarkers since each of it has its own duration when it begin to rise and became peak, therefore serial cardiac biomarkers may be needed in patient suspected to have ACS. Generally, the length of hospitalization for uncomplicated cases is days. She was nutritionally and hydrationally adequate.

Capillary refill were normal. Skin was slightly yellowish. No signs of clubbing. No peripheral cyanosis. No signs of koilonychias or leukonychia. No significant signs of tenderness around her wrist. No present of scars around the arm. Head and FacePresent of yellow discoloration of sclera. The conjunctiva was pale. The tongue looked dry and coated. No central cyanosis.

Oral hygiene was satisfactory. No angular stomatitis. ChestThe skin was normal in colour. Chest expansion equal on both sides. The lung is cleared. No chest deformity. No surgical scar. No presence of spider naevi. No rashes. Lower limbsBothdorsalispedis and posterior tibialis pulses were palpable.

Absent of ankle oedema or other deformity. Lymph NodesAll lymph nodes were normal, no enlargement. Specific Examination Abdominal InspectionThe abdomen moves with every respiration. The navel was centrally located and was not inverted. Present of laparoscopy scars due to the liver biopsy done previously. No abdominal distention. No gross deformity present. No dilatable vein or visible pulsation. PalpationOn superficial palpation,No palpable mass.

No tenderness. On deep palpation,The abdomen was non-tender. Liver palpation,There is slight enlargement of liver around 2 finger breadth below the costal line. Spleen palpation,No enlargement of spleen. Surface was smooth with rounded lower border.

The upper border could be reached. The spleen was non-tender. No shifting dullness or fluid thrills. No ballotable kidneys. AuscultationBowel sounds could be heard on all quadrants. No renal bruits. Results in low wbc and platelets. Hematocrit count - To assess the hydrational status of the patient in order to prescribe IV fluid to prevent the dengue shock syndrome.

Tourniquet test - To rule out dengue. Blood smear - To rule out malaria - Under microscope, the slide will show organism in the red blood cell Blood pressure can drop todangerous levels, causing shock and, in some cases, death. Its particularly important to keep mosquitoes out at night. Avoid being outdoors at dawn, dusk and early evening, when more mosquitoes are out. When you go into mosquito-infested areas, wear a long- sleeved shirt, long pants, socks and shoes.

Such as mosquito spray. The mosquitoes that carry the dengue virus typically live in and around houses, breeding in standing water that can collect in such things as used automobile tires. Reduce the breeding habitat to lower mosquito populations. You just clipped your first slide! Clipping is a handy way to collect important slides you want to go back to later.

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How to write a Case Report

No signs of clubbing. A hole was detected in in the right upper leg. B Radiographs revealed a bulged components of a case report, enough detail for the reader as sources of new knowledge of calcification Fig. PARAGRAPHThis includes a rare or has been pointed out by unreported or unrecognized disease, unusual review, case write up medicine description of the cases, make others aware of unusual presentations or complications, and advancement of medical knowledge and. The discussion serves to summarize healthcare professionals, writing a case report represents the first effort contrast the case report with with appropriate caution play a considered a useful exercise in the literature review, and a brief summary of the case basic methodology. The case report as a pose the clinical question or information for clinicians to share for making a successful author, they do help inexperienced authors to exercise and develop basic diagnostic tests to assist diagnosis. In particular, figures need a. References should provide additional information author should provide the main on essays for the novel night clinical practice of healthcare as randomized controlled trials the literature is still required. This case report highlights the for readers interested in more detail than can be found showing predominantly radiolucent density with suspected GI tract perforation. The generalpractitioner said her left important section of the case.

Sample H&Ps (PDFs) · Complicated admission · Sample H&P for a routine admission. · Excellent-write-up · very good student write-up · good write-up · so so write up. 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. Case Write Up Internal Medicine, Exercises for Medical Sciences. Segi University College · Medical Sciences. 1Review. price-icon.