Patient case study

Introduction

Case studies are an invaluable record of the clinical practices of a profession. While case studies cannot provide specific guidance for the management of successive patients, they are a record of clinical interactions which help us to frame questions for more rigorously designed clinical studies. Case studies also provide valuable teaching material, demonstrating both classical and unusual presentations which may confront the practitioner. Quite obviously, since the overwhelming majority of clinical interactions occur in the field, not in teaching or research facilities, it falls to the field practitioner to record and pass on their experiences.

A case study is a story about something unique, special, or interesting—stories can be

about individuals, organizations, processes, programs, neighborhoods, institutions, and

even events.1 The case study gives the story behind the result by capturing what happened

to bring it about, and can be a good opportunity to highlight a project’s success, or to

bring attention to a particular challenge or difficulty in a project. Cases2 might be selected

because they are highly effective, not effective, representative, typical, or of special interest.

Elements of a patients Case Study

Case studies do not have set elements that need to be included; the elements of each will

vary depending on the case or story chosen, the data collected, and the purpose (for

example, to illustrate a best case versus a typical case). However, case studies typically

describe a program or intervention put in place to address a particular problem. Therefore,

we provide the following elements and example on which you might draw:

1. The Problem

i. Identify the problem

ii. Explain why the problem is important

iii. How was the problem identified?

iv. Was the process for identifying the problem effective?

2. Steps taken to address the problem

3. Results

4. Challenges and how they were met

5. Beyond Results

6. Lessons Learned

Guideline of patient case study

1. Title page:
1. Title: The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet. They may have to decide, just by looking at the title, whether or not they want to access the full article. A title which is vague or non-specific may not attract their attention. Thus, our title should contain the phrase “case study,” “case report” or “case series” as is appropriate to the contents. The two most common formats of titles are nominal and compound. A nominal title is a single phrase, for example “A case study of hypertension which responded to spinal manipulation.” A compound title consists of two phrases in succession, for example “Response of hypertension to spinal manipulation: a case study.”

2. Other contents for the title page should be as in the general JCCA instructions to authors. Remember that for a case study, we would not expect to have more than one or two authors. In order to be listed as an author, a person must have an intellectual stake in the writing – at the very least they must be able to explain and even defend the article. Someone who has only provided technical assistance, as valuable as that may be, may be acknowledged at the end of the article, but would not be listed as an author. Contact information – either home or institutional – should be provided for each author along with the authors’ academic qualifications. If there is more than one author, one author must be identified as the corresponding author – the person whom people should contact if they have questions or comments about the study.
1. Key words: Provide key words under which the article will be listed. These are the words which would be used when searching for the article using a search engine such as Medline. When practical, we should choose key words from a standard list of keywords, such as MeSH (Medical subject headings). A copy of MeSH is available in most libraries.
2. Abstract: Abstracts generally follow one of two styles, narrative or structured.A narrative abstract consists of a short version of the whole paper. There are no headings within the narrative abstract. The author simply tries to summarize the paper into a story which flows logically.A structured abstract uses subheadings. Structured abstracts are becoming more popular for basic scientific and clinical studies, since they standardize the abstract and ensure that certain information is included. This is very useful for readers who search for articles on the internet. Often the abstract is displayed by a search engine, and on the basis of the abstract the reader will decide whether or not to download the full article (which may require payment of a fee). With a structured abstract, the reader is more likely to be given the information which they need to decide whether to go on to the full article, and so this style is encouraged. The JCCA recommends the use of structured abstracts for case studies.

Since they are summaries, both narrative and structured abstracts are easier to write once we have finished the rest of the article. We include a template for a structured abstract and encourage authors to make use of it. Our sub-headings will be:

1. Introduction: This consists of one or two sentences to describe the context of the case and summarize the entire article.
2. Case presentation: Several sentences describe the history and results of any examinations performed. The working diagnosis and management of the case are described.
3. Management and Outcome: Simply describe the course of the patient’s complaint. Where possible, make reference to any outcome measures which you used to objectively demonstrate how the patient’s condition evolved through the course of management.
4. Discussion: Synthesize the foregoing subsections and explain both correlations and apparent inconsistencies. If appropriate to the case, within one or two sentences describe the lessons to be learned.
3. Introduction: At the beginning of these guidelines we suggested that we need to have a clear idea of what is particularly interesting about the case we want to describe. The introduction is where we convey this to the reader. It is useful to begin by placing the study in a historical or social context. If similar cases have been reported previously, we describe them briefly.
4. Case presentation: This is the part of the paper in which we introduce the raw data. First, we describe the complaint that brought the patient to us. It is often useful to use the patient’s own words. Next, we introduce the important information that we obtained from our history-taking. We don’t need to include every detail – just the information that helped us to settle on our diagnosis. Also, we should try to present patient information in a narrative form – full sentences which efficiently summarize the results of our questioning. In our own practice, the history usually leads to a differential diagnosis – a short list of the most likely diseases or disorders underlying the patient’s symptoms. We may or may not choose to include this list at the end of this section of the case presentation.

The next step is to describe the results of our clinical examination. Again, we should write in an efficient narrative style, restricting ourselves to the relevant information. It is not necessary to include every detail in our clinical notes.

If we are using a named orthopedic or neurological test, it is best to both name and describe the test (since some people may know the test by a different name). Also, we should describe the actual results, since not all readers will have the same understanding of what constitutes a “positive” or “negative” result.

X-rays or other images are only helpful if they are clear enough to be easily reproduced and if they are accompanied by a legend. Be sure that any information that might identify a patient is removed before the image is submitted.

At this point, or at the beginning of the next section, we will want to present our working diagnosis or clinical impression of the patient.

6. Management and Outcome: In this section, we should clearly describe the plan for care, as well as the care which was actually provided, and the outcome.

It is useful for the reader to know how long the patient was under care and how many times they were treated. Additionally, we should be as specific as possible in describing the treatment that we used. It does not help the reader to simply say that the patient received “chiropractic care.” Exactly what treatment did we use? If we used spinal manipulation, it is best to name the technique, if a common name exists, and also to describe the manipulation. Remember that our case study may be read by people who are not familiar with spinal manipulation, and, even within chiropractic circles, nomenclature for technique is not well standardized.

We may want to include the patient’s own reports of improvement or worsening. However, whenever possible we should try to use a well-validated method of measuring their improvement. For case studies, it may be possible to use data from visual analogue scales (VAS) for pain, or a journal of medication usage.

7. Discussion: In this section we may want to identify any questions that the case raises. It is not our duty to provide a complete physiological explanation for everything that we observed. This is usually impossible. Nor should we feel obligated to list or generate all of the possible hypotheses that might explain the course of the patient’s condition. If there is a well established item of physiology or pathology which illuminates the case, we certainly include it, but remember that we are writing what is primarily a clinical chronicle, not a basic scientific paper. Finally, we summarize the lessons learned from this case.
8. Acknowledgments: If someone provided assistance with the preparation of the case study, we thank them briefly. It is neither necessary nor conventional to thank the patient (although we appreciate what they have taught us). It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper.
9. References: References should be listed as described elsewhere in the instructions to authors. Only use references that you have read and understood, and actually used to support the case study. Do not use more than approximately 15 references without some clear justification. Try to avoid using textbooks as references, since it is assumed that most readers would already have this information. Also, do not refer to personal communication, since readers have no way of checking this information.
10. Legends: If we used any tables, figures or photographs, they should be accompanied by a succinct explanation. A good rule for graphs is that they should contain sufficient information to be generally decipherable without reference to a legend.
11. Tables, figures and photographs should be included at the end of the manuscript.
12. Permissions: If any tables, figures or photographs, or substantial quotations, have been borrowed from other publications, we must include a letter of permission from the publisher. Also, if we use any photographs which might identify a patient, we will need their written permission.

In practice, case studies should include:

• A description of the client’s presenting problem and the initial context/circumstances of their case. NB: The focus should be on that which is essential to foster the reader’s understanding; incidental details which do not contribute directly to the reader’s understanding should be omitted;

• A description of the ‘trigger’ incident, for example a traumatic event, if applicable;

• The client’s symptoms and the resulting consequences/sequelae, for example detrimental effect on the client’s relationships and constraints on their mobility as a consequence of, for instance, trauma;

• In short, case studies should focus on a description of the problem and the relevant circumstances, the consequences for the client and/or others, the treatment provided and the outcome.

Formats of patients case study

Section	Information to Include
Introduction (patient and problem)	Explain who the patient is (Age, gender, etc.) Explain what the problem is (What was he/she diagnosed with, or what happened?) Introduce your main argument (What should you as a nurse focus on or do?)
Pathophysiology	Explain the disease (What are the symptoms? What causes it?)
History	Explain what health problems the patient has (Has she/he been diagnosed with other diseases?) Detail any and all previous treatments (Has she/he had any prior surgeries or is he/she on medication?)
Nursing Physical Assessment	List all the patient’s health stats in sentences with specific numbers/levels (Blood pressure, bowel sounds, ambulation, etc.)
Related Treatments	Explain what treatments  the patient is receiving because of his/her disease
Nursing Care Plan
Nursing Diagnosis & Patient Goal	Explain what your nursing diagnosis is (What is the main problem for this patient? What need to be addressed?) Explain what your goal is for helping the patient recover (What do you want to change for the patient?)
Nursing Interventions	Explain how you will accomplish your nursing goals, and support this with citations (Reference the literature)
Evaluation	Explain how effective the nursing intervention was (What happened after your nursing intervention? Did the patient get better?)
Recommendations	Explain what the patient or nurse should do in the future to continue recovery/improvement

Example

Asthma Case Study

A 37 y/o black female with a history of asthma, presents to the ER with tachypnea, and acute shortness of breath with audible wheezing. Patient has taken her prescribed medications of Cromolyn Sodium and Ventolin at home with no relief of symptoms prior to coming to the ER. A physical exam revealed the following: HR 110, RR 40 with signs of accessory muscle use. Ausculation revealed decreased breath sounds with inspiratory and expiratory wheezing and pt was coughing up small amounts of white sputum. SaO2 was 93% on room air. An arterial blood gas (ABG) was ordered with the following results: pH 7.5, PaCO2 27, PaO2 75. An aerosol treatment was ordered and given with 0.5 cc albuterol with 3.0 cc normal saline in a small volume nebulizer for 10 minutes. Peak flows done before and after the treatment were 125/250 and ausculation revealed loud expiratory wheezing and better airflow. 20 minutes later a second treatment was given with the above meds. Peak flows before and after showed improvements of 230/360 and on ausculation there was clearing of breath sounds and much improved airflow. RR was 24 at this time and HR 108. Symptoms resolved and patient was given prescription for inhaled steroids to be used with current home meds. Instruction was given for use of inhaled steroids and the patient was sent home.

 

 

References

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