The working diagnosis and management of the case are described. Synthesize the foregoing subsections and explain both correlations and apparent inconsistencies. If appropriate to the case, within one or two sentences describe the lessons to be learned. At the beginning of these guidelines we suggested that we need to have a clear idea of what is particularly interesting about the case we want to describe.
The introduction is where we convey this to the reader. It is useful to begin by placing the study in a historical or social context. If similar cases have been reported previously, we describe them briefly. If there is something especially challenging about the diagnosis or management of the condition that we are describing, now is our chance to bring that out.
Each time we refer to a previous study, we cite the reference usually at the end of the sentence. This is the part of the paper in which we introduce the raw data.
First, we describe the complaint that brought the patient to us. Next, we introduce the important information that we obtained from our history-taking. Also, we should try to present patient information in a narrative form — full sentences which efficiently summarize the results of our questioning. We may or may not choose to include this list at the end of this section of the case presentation.
The next step is to describe the results of our clinical examination. 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. 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? 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. 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 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.
A popular search engine for English-language references is Medline: 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. 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.
Name, academic degrees and affiliation. 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: Her headaches are primarily in the suboccipital region, bilaterally but worse on the right.
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