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）或 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 case，rare 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

• “How to Compose a Journal Submission Cover Letter” (Wordvice/YouTube)
• 學術期刊投稿信Cover letter要怎麼寫？
• “40 Useful Words and Phrases for Top-Notch Essays” (Oxford Royale Academy)
• 如何靈活替換論文中的動詞，讓文章更好讀?
• “Essential Academic Writing Words and Phrases” (My English Teacher.eu)
• “Academic Vocabulary, Useful Phrases for Academic Writing and Research Paper Writing” (Research Gate)

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