英文写作 Case Report

Case Report
Case report can divided into three parts, namely, Introduction, Case History, and Discussion.
1, INTRODUCTION is used to tell content, its purpose and significance. It should be as brief, and concise as possible and in present tense.
Sample 1,
Isolated false aneurysms of the innominate artery resulting from penetrating trauma are rare. We present one such case that was successful managed by resection and interposition grafting and emphasize the importance of arch aortography in the management of penetrating thoracic trauma.
Sample 2,
Malignant disease should be remembered in the differential diagnosis of common rheumtological disorders. We present a patient whose pain proved to be due to malignant disorder and not to simple trochanteric bursitis.
2, CASE HISTORY consists of the patient’s gender, age, history, symptoms, tests, diagnosis as well as treatment. Details of the normal test results, the clinical process of post-operational and medication treatment should be recorded when necessary. If more cases are to be reported they should be numbered respectively “case 1”,” case 2”…
2-1, General Introduction of Case History consists of the name, sex, general conditions and complaints of the patient as well as occupation and race if necessary. The real name and residential number shouldn’t be referred to. The language should be brief and in past tense.
Sample 1, a 37-year-old woman with the previously uncomplicated pregnancies was seen 5 months into her third pregnancy with a two-week history of severe lower back pain.
Sample 2, two women, aged 17 and 22 years, came to the accident and emergency department early in the afternoon. They described the acute on set of a diffuse rash 15 to 30 minutes after they had lunched together in a local pub.
2-2 Symptoms and Clinical treatment;
1), to tell about the typical symptoms, complications, diagnosis and treatment instead of other irrelevant materials.
2), to tell about special examining method as well as its result.
3), to tell about medication dosage; either smaller one or bigger one should be marked.
4), to tell about effects of treatment: Are the symptoms relieved? Are there any complications? Are these in expectation?
5), to tell about the result of treatment: Is the patient alive or dead? What are the current conditions? What treatment is the patient to be given?
Sample 1 (description of symptoms), They described the acute onset of a diffuse rash 15 to 30
minutes after they had lunched together in a local pub. Both felt hot and had passed two or three bowel motions. They had no respiratory symptoms and were otherwise systematically well. Neither had ever experienced an allergic reaction and the only medical history of note was that both used occasional salbutamol for mild asthma.
Sample 2 (exanimation); On examination, both had diffuse erythematous rash widely spread over the face, torso and limbs. When symptoms did not resolve she was refereed to hospital where clinical examination revealed saddle anesthesia, reduced anal tone and absent ankle reflexes bilaterally.
Sample 3 (treatment); They were given intravenous chlorpheniramine, hydrocortisone and fluids. After that, they were observed for a few hours and discharged when improved. Note: passive voice should be used in this description.
3, DISCUSSION
To focus on the case and to sum up the special experience and new views from the process of diagnosis and treatment. Present tense is used to show the objectiveness
Sample 1; Intravenous chlorpheniramine and hydrocortisone are helpful in treatment of diffuse erythematous rash.
Sample 2, Many factors contribute to back pain during pregnancy.
Sample 3, Diagnosis of midlife prolapse of a disc causing cauda equine compression is particularly important since a delay in surgical intervention can lead to permanent neurological deficits.
Sample 4, We recommend that in pregnant and postpartum women back pain should not be looked upon merely as a normal occurrence. Detailed history and neurological examination are essential to identify the danger signs.
(from “Back Pain During Pregnancy and After Childbirth: an Unusual Cause Not to Miss）。