CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION
San Pablo, Tarlac City
CASE STUDY FORMAT
I.IntroductionII.ObjectivesNurse centeredIII.Nursing ProcessA.Data Basea.Nursing health history A1.Demographic data2.Chief complaint3.History of present illness4.Past medical history5.Family history6.Social and personal history7.Review of systemb.Nursing health history B1.General Description Of Client2.Health Perception-Health Management Pattern3.Nutritional-Metabolic Pattern4.Elimination Pattern5.Activity-Exercise Pattern6.Sleep-Rest Pattern7.Cognitive-Perceptual Pattern8.Self-Perception – Self-Concept Pattern9.Role-Relationship Pattern10.Sexuality-Reproductive Pattern11.Coping-Stress Tolerance Pattern12.Value-Belief Patternc.Physical examinationd.Laboratory Findingse.Review of anatomy and physiologyf.Pathophysiology (highlight patient manifestation)B.NCPC.Drug StudyD.Medical and Nursing ManagementE.METHODIV.Evaluation
Narrative evaluation of the objectives
Patient condition upon dischargeV.Recommendation
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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