How to Write a Clinical Report
When
writing a clinical report, you must first determine whether your case
report is worthy of publication. Scientific and medical journals seek
specific types of cases including negative responses to therapies,
atypical observations, a combination of factors that created confusion, a
situation that throws a current theory into question, a new theory or,
in some situations, a case that had a dramatic impact on the clinician.
Once you have determined that the case is publishable, selected an
appropriate journal for the submission and get the patient's written
authorization to publish the study.
instructions
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Check the journal or its website to find the publication's instructions for authors. In general, journal articles have a similar structure; however, specific journals may have different requirements. Before writing, read articles from the selected journal to become familiar with composition and structure as well as the amount of detail the editors want or expect
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Write the introduction by outlining the bigger problem the
case addresses and include citations from medical literature. You are
not detailing the entire case, simply stating the overarching situation
or occurrence. Often the introduction ends with a specific description;
for example, "This case report describes clinical characteristics of a
60-year-old woman with multiple sclerosis and acute depression."
Present the case in detail. Open by describing the
individual and her situation from the onset of the disease or condition
to the present. Detail the physical exam, pertinent test results and
detailed information on the prescribed treatment. Finally, distinguish
the expected outcome from the actual result where the atypical or
abnormal occurrence took place.
Include the literature review, focusing on research findings
that point to what the outcome of the treatment should have been and
how the actual event or occurrence departed from the expected outcome
detailed in the literature. Generally, if you are citing research
throughout the work, it is best to present general research findings in
the introduction and the more specific findings in the discussion.
Write the discussion, being mindful that it is the most
important part of the study. Detail why your case is singular or
exceptional and outline specific circumstances or instances that make it
puzzling or atypical. Describe the discovery of the atypical outcome
and contrast it to the expected outcome. If this case flies in the face
of an existing theory, you might propose a new one.
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