2018年 08月 08日

如何撰寫醫學病例報告標題及摘要

醫學論文是與數學、自然科學、社會科學和工程技術均有所不同的一類特殊的學術論文,種類較多,體裁各異,主要包括以下七類:(1)論著類,(2)綜述、講座類,(3)病例報告類,(4)簡報類,(5)評論類,(6)會議紀要類,(7)消息動態類。 其中,病例報告(case report)通常記錄和總結臨床中少見但具有特殊意義的病例。 這類論文有新意,實用價值高,被很多讀者所喜愛。 特別是針對罕見病症的首例報導,能夠引發新的研究熱點,在國內外具有重要影響力。

病例報告像其他論文一樣,其完整的寫作格式包括標題、摘要、關鍵字、引言、病例描述、討論、結論、參考文獻、致謝等部分。 其中,標題和摘要特別重要,因為它們是讀者最先看到的內容,如果寫得不好,讀者可能會放棄閱讀。 由於病例報告在題材上具有特殊性,在標題和摘要的寫作上也具有一些特殊規定,本文予以簡述。

病例報告的四大特點

  1. 病例報告主要揭示罕見疾病、新發疾病和疑難重症,也可以報告已知疾病的從未被人們認識的特殊臨床表現、特殊鑒別診斷病例、創新治療經驗。 有些病例雖然曾經有過少數類似報導,但如果有必要重複驗證或加深認識,就可以寫成病例報告發表。
  2. 病例報告可以是單一病例的個案分析,也可以針對一組系列病例。 當病例數量較少時,不具有統計學意義。 當病例數量足夠大時,可以進行統計概率分析。 這些會影響病例報告的寫法。
  3. 病例報告必須內容確切,病例資料完整,診斷具有科學依據。 通過對診治過程的論述體現診療思維。 臨床病理討論具有較強的針對性。
  4. 病例報告是臨床研究的基礎,是一種重要的醫學學術交流方式,廣泛用於各種學術會議和競賽活動,也可以發表在期刊。

病例報告的選刊投稿

雖然很多高影響因數期刊都開闢專欄接受病例報告,但並不是每個醫學期刊都允許刊登病例報告。 某些期刊只發表少量的病例報告,但是也有很多著名學術期刊專門發表病例報告,其中很多是開放獲取期刊,例如:Journal of Medical Case Reports,  Oxford Medical Case Reports,  BJR Case Reports,  International Journal of Surgery Case Reports

每個醫學期刊都有自己的投稿格式規定,通常刊登在期刊網站的以下位置:Instructions for  Authors,Author  Guidelines,Preparing  Your  Manuscript。 作者需根據期刊的投稿規定調整論文格式。

病例報告的標題

標題需要簡明扼要地反映病例資訊,並能夠吸引讀者。 病案數量應包括在標題中。 但是,case study(病例研究) case report(病例報告)這些詞在標題中其實是多餘的,應盡量避免。 常見的病例報告標題的例子包括:”…… 病的診治”,”…… 病的診斷”,”…… 病的診斷與療效觀察”等。

有些英文詞彙專門用於英文病例報告的標題,包括:presentation, unusual caserare case,  challenges, complications, symptoms, causes, diagnosis, treatment。 另外,在英文病例報告的標題中常用的與病患相關的詞彙包括:patient, adult, child, infant, adolescent, elderly, man,  woman。 下面給出幾個比較好的標題例子:

  • 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

病例報告的摘要

病例報告摘要的寫法須遵循學術論文摘要寫法的一般準則,需要包括引言(研究背景和目的)、方法、病例描述、討論和結論等部分的簡要概述。

研究背景和目的

摘要中涉及的研究背景和目的通常由1~2句組成,說明報告該病例的原因,並簡述創新性和臨床相關性。

如果字數允許,可以加入患者或其監護人的知情同意資訊和倫理委員會審批資訊。

研究背景和目的中包括的內容 寫作示例
醫療條件,醫療程式,醫療方法
  • Inferior glenohumeral joint dislocations are rare.
  • Due to severe swelling and overlapping of bones on an X-way of the wrist and hand, dislocations are missed.
關於病例重要性的解釋
  • The objective of this clinical case report is to highlight the unusual injury to avoid incorrect diagnosis.

病例描述

摘要中涉及的病例描述的部分通常用3~6句組成,簡要說明病患的醫療情況、患者特徵、病因病機、診斷結論、治療干預、併發症、治療效果等。 該病例對醫學創新性貢獻越大,就越值得詳述。

病例描述中包括的內容 寫作示例
病人資料,包括年齡、性別、國籍等
  • a 35-year-old man
  • a 1-month-old infant
  • a 12-year-old Somali girl
病症表現
  • demonstrated typical signs and symptoms of Huntington’s Disease
  • presented to the hospital with severe chest pain
  • experienced a burning sensation due to swollen leg muscles
病史和癥狀
  • reported a long history of asthma
  • had a family history of colon cancer on the maternal side
  • reported that inflammation had begun one year prior
診斷
  • Based on the characteristics appearance of the cutaneous lesions, a diagnosis of granuloma annulare was made.
  • A clinical diagnosis of chronic respiratory disease was made.
  • Intestinal legions were consistent with severe Crohn’s Disease.
治療
  • The patient was immediately intubated and antitubercular therapy was initiated.
  • Treatment was initiated with low-dose corticosteroids, anticoagulants, and vasodilators.
醫療程式
  • Following kidney biopsy, renal cysts were excised laparoscopically.
  • The patient underwent three skin grafts.
  • An emergency arteriogram showed smooth segmental narrowing and bilateral vasospasm.
併發症
  • Additional history revealed that he had been ingesting ergotamine preparations for a number of years to relieve chronic muscle pain.
  • Laparoscopic access to the duodenum was inhibited by intra-abdominal fat.
醫療結果
  • Patient was asymptomatic on subsequent visits.
  • Although scapular swelling subsided, she continued to report severe back pain for the following month.
  • … resulting in significant improvement within 4 hours and resolution of symptoms within 48 hours.

討論和結論

摘要中涉及的討論和結論通常使用1~2句簡要陳述臨床影響和病例意義,併為臨床領域提供建議,包括強調病例涉及的廣泛影響、建議的預防措施和未來的相關研究課題。

討論與結論包括的內容 寫作示例
總體臨床影響
  • Each of these tests has a high negative predictive value but a poor positive predictive value.
  • Identifying and reporting anomalous enzymes is an important service the clinical lab technician can provide a clinician.
建議
  • Even when strict protocol is followed, clinicians must remain alert to the potential for medical errors related to misinterpretation of laboratory test results based on similar samples.
  • SRED should be considered a possible implication of sedative hypnotics.
病例影響
  • An atypical isoenzyme test may result from a macroenzyme, the presence of which can complicate interpretation of the test result and may lead to further unnecessary procedures.
  • Antiviral therapy may significantly reduce mortality for patients who have risk factors identified.

醫學病例報告摘要範本

Example #1: A Case of Injury

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].

Example #2: A Case of Disease/Disorder

[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.].

其他參考連結

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