医学论文是与数学、自然科学、社会科学和工程技术均有所不同的一类特殊的学术论文,种类较多,体裁各异,主要包括以下七类:
(1)论著类,(2)综述、讲座类,(3)病例报告类,(4)简报类,(5)评论类,(6)会议纪要类,(7)消息动态类。
其中,病例报告(case report)通常记录和总结临床中少见但具有特殊意义的病例。这类论文有新意,实用价值高,被很多读者所喜爱。特别是针对罕见病症的首例报道,能够引发新的研究热点,在国内外具有重要影响力。
病例报告像其他论文一样,其完整的写作格式包括标题、摘要、关键词、引言、病例描述、讨论、结论、参考文献、致谢等部分。其中,标题和摘要特别重要,因为它们是读者最先看到的内容,如果写得不好,读者可能会放弃阅读。
由于病例报告在题材上具有特殊性,在标题和摘要的写作上也具有一些特殊规定,本文予以简述。
一、病例报告的四大特点
1. 病例报告主要揭示罕见疾病、新发疾病和疑难重症,也可以报告已知疾病的从未被人们认识的特殊临床表现、特殊鉴别诊断病例、创新治疗经验。有些病例虽然曾经有过少数类似报道,但如果有必要重复验证或加深认识,就可以写成病例报告发表。
2. 病例报告可以是单一病例的个案分析,也可以针对一组系列病例。当病例数量较少时,不具有统计学意义。当病例数量足够大时,可以进行统计概率分析。这些会影响病例报告的写法。
3. 病例报告必须内容确切,病例资料完整,诊断具有科学依据。通过对诊治过程的论述体现诊疗思维。临床病理讨论具有较强的针对性。
4. 病例报告是临床研究的基础,是一种重要的医学学术交流方式,广泛用于各种学术会议和竞赛活动,也可以发表在期刊。
二、病例报告的选刊投稿
虽然很多高影响因子期刊都开辟专栏接受病例报告,但并不是每个医学期刊都允许刊登病例报告。某些期刊只发表少量的病例报告,但是也有很多著名学术期刊专门发表病例报告,其中很多是开放获取期刊,例如:Journal of Medical Case Reports, Oxford Medical Case Reports, BJR Case Reports, International Journal of Surgery Case Reports。
每个医学期刊都有自己的投稿格式规定,通常刊登在期刊网站的以下位置:Instructions for Authors,Author Guidelines,Preparing Your Manuscript。作者需根据期刊的投稿规定调整论文格式。
三、病例报告标题
标题需要简明扼要地反映病例信息,并能够吸引读者。病案数量应包括在标题中。但是,case study(病例研究)或 case report(病例报告)这些词在标题中其实是多余的,应尽量避免。常见的病例报告标题的例子包括:病的诊治,病的诊断,病的诊断与疗效观察等。有些英文词汇专门用于英文病例报告的标题,包括:presentation, unusual case, rare case, challenges, complications, symptoms, causes, diagnosis, treatment。另外,在英文病例报告的标题中常用的与病患相关的词汇包括:patient, adult, child, infant, adolescent, elderly, man, woman。下面给出几个比较好的标题例子:
An unusual presentation of primary small lymphocytic lymphoma (SLL) in an elderly woman
Challengesin 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
四、病例报告摘要
病例报告摘要的写法须遵循学术论文摘要写法的一般准则,需要包括引言(研究背景和目的)、方法、病例描述、讨论和结论等部分的简要概述。
1. 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句组成,说明报告该病例的原因,并简述创新性和临床相关性。如果字数允许,可以加入患者或其监护人的知情同意信息和伦理委员会审批信息。
研究背景和目的中包括的内容 | 写作示例 |
医疗条件,医疗程序,医疗方法 |
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. |
关于病例重要性的解释 | The objective of this clinical case report is to highlight the unusual injury to avoid incorrect diagnosis. |
2. 病例描述:
摘要中涉及的病例描述的部分通常用3~6句组成,简要说明病患的医疗情况、患者特征、病因病机、诊断结论、治疗干预、并发症、治疗效果等。该病例对医学创新性贡献越大,就越值得详述。
病例描述中包括的内容 | 写作示例 |
病人资料,包括年龄、性别、国籍等 |
a 35-year-old man a 1-month-old infant a 12-year-old Somali girl |
病症表现 |
demonstrated typical signs and symptoms of Huntingtons Disease presented to the hospital with severe chest pain experienced a burning sensation due to swollen leg muscles |
病史和症状 |
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 |
诊断 |
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 Crohns Disease. |
治疗 |
The patient was immediately intubated and antitubercular therapy was initiated. Treatment was initiated with low-dose corticosteroids, anticoagulants, and vasodilators. |
医疗程序 |
Following kidney biopsy, renal cysts were excised laparoscopically. The patient underwent three skin grafts. An emergency arteriogram showed smooth segmental narrowing and bilateral vasospasm. |
并发症 |
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. |
医疗结果 |
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. |
3. 讨论和结论:
摘要中涉及的讨论和结论通常使用1~2句简要陈述临床影响和病例意义,并为临床领域提供建议,包括强调病例涉及的广泛影响、建议的预防措施和未来的相关研究课题。
讨论和结论中包括的内容 | 写作示例 |
总体临床影响 |
Each of these tests has a high negative predictive value but apoor positive predictive value. Identifying and reporting anomalous enzymes is an importantservice the clinical lab technician can provide a clinician. |
建议 |
Even when strict protocol is followed, clinicians must remainalert 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 sedativehypnotics. |
病例影响 |
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 forpatients who have risk factors identified. |
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