撰写模板
标题。在标题中加入词语“案例报告”。描述最受关注的现象(例如症状、诊断、测试、干预)。
关键词。为潜在读者提供 2 至 5 个关键词，有助于其搜索、查找本案例报告。
摘要。案例添加了什么内容?案例简报应包括 (1) 患者的主要症状，(2) 主要临床发现，(3) 主要诊断和 干预，(3) 结果，和 (4) 主要结果。结论:从案例“获取的”主要经验是什么?
简介。简要概述案例的背景，提及相关的医学文献。
患者信息。提供人口统计信息(例如年龄、性别、种族、职业);患者的主要症状(主要病症);医 疗、家庭和心理历史-包括饮食、生活方式和遗传信息(只要可能)以及关于相关的共病详情，包括过 往的干预及其结果。
临床发现。描述相关的身体检查 (PE) 发现。
时间表。描述本案例中的重要日期和时间(表格或图)。
诊断评估。评估 (1) 诊断方法(例如 PE、实验室测试、成像、调查问卷);(2) 诊断挑战(例如财力、 语言/文化);(3) 诊断推理，包括其他已考虑的诊断，和 (4) 预后特征(例如分期)(如适用)。
治疗干预。描述(1) 干预的类型(例如药物、手术、预防性、自我护理);(2) 干预的管理(例如剂量、 强度、持续时间);以及干预的任何改变(供理论依据)。
跟进和结果。概述所有跟进就诊的临床过程，包括 (1) 临床医生和患者评估结果;(2) 重要跟进测试结 果;(3) 干预遵从性和耐受性(如何评估这点);和 (4) 不良和意外事件。
讨论。请描述(1) 本案例报告的强度和限制;(2) 相关的医学文献;(3) 结论的理论依据(包括原因和效 果的评估);和 (4) 从案例报告“获取的”主要经验。
患者观点。患者应分享其观点或经验(只要可能)。
知情同意书。患者是否提供知情同意书?请在要求时提供。
1. 利益冲突。是否存在任何利益冲突?
2. 道德批准。道德委员会或机构审查委员会是否提供批准?如是，请在要求时提供。
3. 去识别化。所有患者相关数据是否已被去识别化?
General Considerations. Please ensure that all patient data has been de-identified and that you obtained the necessary approval, if necessary, from an ethics commission or an institutional review board. Do you have any competing interests?
Title. Include the words “case report” in the title. Describe what is of greatest interest to you the author. This could the presentation, the diagnosis, a test result, the intervention, or the outcome.
Abstract. In about 200 words summarize the following information if relevant: (1) Rationale for this case report, (2) Presenting concerns of the patient (esuch as chief complaints or symptoms, diagnoses), (3) Interventions (such as diagnostic, preventive, prognostic, therapeutic exchange), (3) Outcomes, and (4) Main lesson(s) to learn from this case report.
Key Words. Provide 2 to 5 key words that will help potential readers search for and find this case report.Introduction. Briefly summarize the background and context of this case report.
Presenting Concerns. Describe the patient characteristics (such as the relevant demographics—age, gender, ethnicity, occupation) and their presenting concerns with relevant details of related past interventions.
Clinical Findings. Describe the (1) medical, family, and psychosocial history including lifestyle and genetic information; (2) other pertinent co-morbidities and interventions (other therapies including self- care); and (3) the physical examination (PE) focused on the important findings including results from testing.
Timeline. Create a timeline that includes specific dates and times in a table, figure, or graphic. Visitwww.care-statement.org/case-report-examples for one example of a case report timeline.
Diagnostic Focus and Assessment. Provide an assessment of the (1) diagnostic methods
(including laboratory testing, imaging results, questionnaires, referral diagnositc information); (2) diagnostic challenges (such as limited ability to complete an evaluation, patient availability, cultural); (3) diagnostic reasoning including other diagnoses considered, and (4) prognostic characteristics (such
as staging in oncology) where applicable.
Therapeutic Focus and Assessment. Describe the (1) types of interventions (such as pharmacologic, surgical, preventive, lifestyle, self-care) and (2) administration and intensity of the intervention (including dosage, strength, duration, frequency).
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Follow-up and Outcomes. Please describe the clinical course of this case including all follow-up visits as well as (1) intervention modification, interruption, or discontinuation, and the reasons; (2) adherence to the intervention and how this was assessed; and (3) adverse effects or unanticipated events. Please describe (1) patient-reported outcomes, (2) clinician assessed and reported outcomes, and (3) important positive and negative test results.
Discussion. Please describe the strengths and limitations of this case report including case management, and the scientific and medical literature related to this case report. Discuss the rationale for your conclusions such as potential causation and the ways this case might be generalized to a larger population. Finally, what are the main findings of this case report and what are the 'take-away' messages?
Informed Consent. Ensure that the patient provided their informed consent for the publication of this case report.
