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医疗及临床病例报告之目的为记录特殊或罕见疾病、病症及损伤等病例,这些报告不只提供了每个病例的详细状况,亦简要的涵盖了相关背景资料,并为现有的医学文献建立重要的附加价值。
在研究者有机会阅读到您所撰写的病例报告之前,他们首先会搜寻摘要目录,以便找出与他们的医学研究所相关的信息。因此,将病例报告中的关键内容呈现于标题中,以及简要的撰写于摘要中,是十分重要的。以下将提供撰写医学病例报告的技巧及范例,以帮助您投稿至病例报告杂志。
这里所提供的技巧适用于投稿至大部份的医学杂志,但是,每个杂志对于内容和格式都有各自的准则,建议您可参考各杂志的“Instructions for authors”,“Author guidelines” ,或是“Preparing your manuscript” ,以了解相关准则。另外,阅读不同杂志的病例报告也有助于您了解各杂志所特定的格式及风格。
有些医学杂志会发表有限数量的病例报告,除此之外,亦有许多权威性的同行审稿医学杂志,专门刊登病例报告。包括: Journal of Medical Case Reports, Oxford Medical Case Reports, BJR Case Reports, and International Journal of Surgery Case Reports 。这些杂志都是您可以选择投稿的。
标题是病例报告读者所最先阅读到的部份,因此,标题应要能提供重要信息、与主题高度相关,并且简明扼要。另外,标题应要能吸引研究者和其他读者的注意力,并同时保有可信度和说服力。
病例相关用语: presentation, unusual case, rare case, challenges, complications, symptoms, causes, diagnosis, treatment
病患相关用语: patient, adult, child, infant, adolescent, elderly, man/woman
与”文章”相关的用语,例如: case study 或是 case report 会被认为是多余的,并且会让读者失去兴趣,在订定标题时应注意避免使用这些用语。
“An unusual presentation of primary small lymphocytic lymphoma (SLL) in an elderly woman”
“Challenges in the management of mycotic splenic arteriovenous fistula in a cirrhotic patient”
“CREST syndrome: a rare cause of chronic upper-gastrointestinal Hemorrhage in adults”
“Primary tuberculous dacryocystitis: two cases mimicking tumors of the lacrimal sac”
摘要必须要简明扼要、完整度高,并要能让读者在阅读您的文章之前,能够有一个全面性的概念。
1. 背景(1-2个句子)—首先,解释为何您选择撰写这个病例报告,并叙述报告的创新性及临床相关性。
2. 病例呈现 (3-6个句子)—简明扼要的说明病患的医疗及背景特征之详细状况、治疗处方、处理措施、或是并发症及结果。叙述内容之详细度取决于创新程度以及病例结果。
3. 讨论/结果 (1-2个句子)—简单摘要临床影响及病例涵义,并为临床领域提供建议。强调病例中有可能涉及更广层面涵义之部份、建议应采行的预防措施,或在未来研究中可以发展的有趣题目。
We herein report a case of a [patient age and gender] with an unusual case of [injury]. The [injury] consisted of features typical of [common features of the injury/disease/disorder], with additional [additional features of case, if any], signifying a [diagnosis/complications]. Features of this case are discussed together with its implications, including [implications of case]. [Additional measures taken—treatment/surgery/etc.] was undertaken due to [reason for measures].
[Disease/disorder] is a rare condition characterized by [symptoms]. Its presentation is usually [sporadic/chronic/acute]. Usually seen in patients who are [typical demographics of patient], [disease]presentation in [this specific category of patient] is rare. Symptoms at presentation depend on [parts of body/patient’s environment]. Patients with [disease/disorder] may present with [additional major symptoms]. We herein report a rare presentation of [disease/disorder] in a [patient demographic—age/gender/race/etc.] who suffered from [corresponding symptoms or co-morbid diseases]. [Diagnostics/tests] revealed [results of tests/complication]. The patient underwent [surgery/treatment] and was given [drugs/intubation/etc.]. Recovery was [description of recovery]. In spite of a wide range of therapeutic options for the management of [disease/disorder] described in the literature, the efficacy of those available therapies is [unknown/not well established/open/etc.].
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