Medical case write up example. How to write a medical case report 2022-10-27
Medical case write up example
A medical case write-up is a detailed report of a patient's medical history, examination, and treatment. It is typically written by a healthcare provider, such as a doctor or nurse, and is used to document the patient's care and to communicate important information to other members of the healthcare team. In this essay, we will take a look at an example of a medical case write-up to understand its purpose, structure, and content.
The patient in this example is a 60-year-old woman who presents with a cough and shortness of breath. She has a history of asthma, but her symptoms have been worsening over the past week. On examination, the patient is found to have wheezing and reduced breath sounds in her left lung. The healthcare provider orders a chest x-ray, which shows a small left pneumothorax (collapsed lung).
The medical case write-up begins with a summary of the patient's chief complaint and history of present illness. This includes information on the patient's age, gender, and relevant medical history. The write-up then moves on to the physical examination, which includes a description of the patient's vital signs, appearance, and any abnormal findings on examination. In this case, the healthcare provider notes the presence of wheezing and reduced breath sounds in the left lung.
Next, the write-up includes a discussion of the diagnostic tests that were ordered and the results of those tests. In this case, the chest x-ray was ordered, and the result was a small left pneumothorax. The write-up then discusses the diagnosis and the management plan for the patient. In this case, the diagnosis is a left pneumothorax, and the treatment plan includes placing a chest tube to re-inflate the lung and administering oxygen therapy.
The medical case write-up concludes with a summary of the patient's current status and any follow-up care that is planned. In this case, the patient's condition is stable, and she is scheduled for follow-up in one week.
In conclusion, a medical case write-up is a detailed report of a patient's medical history, examination, and treatment. It is used to document the patient's care and to communicate important information to other members of the healthcare team. The structure of a medical case write-up includes a summary of the patient's chief complaint and history of present illness, a description of the physical examination and diagnostic tests, a discussion of the diagnosis and management plan, and a summary of the patient's current status and follow-up care.
It should not exceed 350 words. I will assess the integrity of the valve with an echo and continue the aspirin therapy with aspirin 325 mg orally daily Venous insufficiency: He appears to have bilateral lower extremity venous insufficiency that has started to cause chronic changes and stasis dermatitis. Immunosuppressive therapy needs to be clearly described frequency, dose and drug formulation to allow other clinicians to benefit from this information. He does have a significant history of alcohol abuse. Authors now also have Cases Database, a continually updated, freely accessible database of thousands of medical case reports from multiple publishers. This makes case study a valuable resource for improving our techniques in evaluation and treatments.
SIMPLE Cases in Clerkship
The temporal aspects of the history are presented in an easy to follow fashion, starting with the most relevant distant event and then progressing step-wise to the present. He appears to always been easily rate controlled with lopressor. Wears glasses for reading only. Cell death: the significance of apoptosis. Did you obtain C onsent? He has been referred for admission to the medicine service.
Writing A Case Report
It appears to be consistent with tender hepatomegaly. In a case report where the electrolyte disorder is diagnosed to be the result of disturbance in function of the renal tubules, a thorough attempt should be made at eliminating every other possibility. Patient with chronic bronchitis tend to retain carbon dioxide. No history of thyroid problems or goiter. He has not been very active physically for many years. However, please be aware that poor grammar and frequent spelling mistakes can be an impediment to editorial work flow and peer review.
How to Write a Good Medical History: 6 Steps (with Pictures)
Knowing which past medical events are relevant to the chief concern takes experience. He denies any history of hepatitis. No other significant family history could be obtained. He does have some audible expiratory wheezes. If the patient does turn out to have decompensated liver disease I will add spironolactone 25mg orally daily and titrate this up. He really has not had any sputum production. You can download and refer to this sample for your case study.
UC San Diego's Practical Guide to Clinical Medicine
The diagnosis of acute glomerulonephritis is confirmed only with a kidney biopsy. He has not been bed-bound or hospitalized recently. If, for example, you are describing the course of a truly otherwise healthy 40-year-old who presents with 3 days of cough, fever, and shortness of breath as might occur with pneumonia, you can focus on that time frame alone. The foreskin retracts easily and there are no signs of infection or discharge under the foreskin. Positive history of nocturia approximately 3 times per night. He does have a muffled S1. I will not check lipids during this hospitalization and I will leave this up to his cardiologist once discharged.
How to write a medical case report
Has no symptoms related to tachycardia, impaired ventricular function. He was in the Japanese Navy for many years. No pulmonary artery pressure was calculated. When there is time for a complete history, it can include primary, secondary and tertiary histories of the chief complaint, a review of the patient's symptoms, and a past medical history. Cardiac cirrhosis from long standing right-sided failure is unlikely given his normal right ventricular function and structure on previous echocardiograms.
How to write a medical case study?
S L at the Regional Oncology Center, last seen May, 2003. V Sensation intact at forehead, cheeks and jaw bilaterally, jaw strength intact. T K became progressively more somnolent at times. The second part of the research is analytical; it means that the student should independently analyze the state of the problem he is studying at a given time. Patients and their stories including from their friends, coworkers, and family are our portal to writing the case report.
Journal of Medical Case Reports
Some benign moles that are followed by his primary care doctor. In the twentieth century, chronic diseases became the main object of medical research. This way of a scientific research and publications took shape in the 17th century. Once you identify a case and have learned what information to include in the case report, try to find a previously published case report. It can also be similar to this template, where the content is arranged into two columns.