Formal Medical Case Report

Formal Medical Case Report

General Instructions:


Health professionals often find themselves writing case reports, in various forms, that rely on careful observation of a patient’s struggle with an illness or other disorder. The case report is a kind of story, one that differs from more literary stories in that the tale it tells appeals not to our emotions, but to our scientific curiosity. It is intended to help those who read it to make diagnoses. It tells the reader what symptoms to look for, and how a disease usually presents itself (which is particularly useful when the disease is new or rare). The clinician does not know, on first seeing a patient, what point the illness has reached in its natural course. The case report helps in this situation by giving a thorough description of the whole course of an illness, and does so by relating an actual instance of the condition as suffered by a real person.

Because you are not yet in the field, you may think that you have no patients about whom to write a case report. You do, however, know a great deal about a variety of diseases and temporary or permanent disabilities, even if they are only the common ones, like a childhood illness, or one of the diseases that frequently appear among the elderly. Any of these topics can—if not too simple—provide the basis for the case report I am asking you to write. So, too, might your knowledge of a more unusual physiological or psychological problem.

For this assignment, write a formal case report, using as a model the case report that I gave you, and using as your subject an actual person. Your next assignment, after this one, will also be a case report, but more “creative” (and will further require that you find a new person to write about). For now, we will be more detached. Your audience is different from the last essay; this time, you should think of the audience as people with a medical education, and you should imagine that you are an expert on the condition you are describing. You will therefore not need much explanation of technical matters, but will probably have some, carefully adjusted for the audience. You should include both the specific course of the condition as suffered by your patient, and a discussion of the condition in general. Support your discussion with at least one source written for a professional audience (you can of course include more than one). You will likely include most of the following:

The patient’s age, gender, ethnicity, economic background, and other such basics.

Careful descriptions of the patient’s health condition. These descriptions must be based on your own observation of the patient, or your discussion with people who know—or knew—the patient. You can write about someone who is deceased; you can also write about an infant, or a person with an illness so advanced that he or she can no longer communicate. In these cases, you will rely on conversations with friends or family of the patient.

Your description of the patient’s health condition should also be highly detailed. You will likely discuss the onset of the problem and its course, as thoroughly and specifically as possible. Remember that one purpose of a case report is to tell those who read it how the disease presents itself through its whole progression. Consider possible triggers to the condition, the severity of episodes, the usual duration, the extent to which physiological and emotional responses change throughout the course of the problem, responses to treatment or palliatives, and much else.

          Do not use yourself as the subject. This is your chance to do real medicine, and take an actual case history. You will miss that chance if other people are excluded.

                  Do not use a real name. Refer to the subject as “the patient.”

                  You must get your subject’s permission to write about him or her. Attach to the paper a signed consent form from the subject, or the equivalent. There is no official form, so just make up a simple one of your ow


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