Case report [Neurosurgery Wiki]

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====== Case report ======

[[Case]] report is a detailed [[report]] of the [[symptom]]s, [[sign]]s, [[diagnosis]], [[treatment]], and [[followup]] of an individual [[patient]]. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a [[literature review]] of other reported cases.

===== Why Case Reports? =====

Data collection from the point of care integrating clinical expertise with external evidence informs the delivery of high-quality individualized healthcare. “Good case reporting demands a clear focus, to make explicit to the audience why a particular observation is important in the context of existing knowledge.” (Vandenbroucke 2001).

see [[CARE guidelines]].

[[General University Hospital of Alicante Cases]]
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====== 🧠 Case Report: [Insert concise case title here] ======

**👨‍⚕️ Authors:**  
[Your Name], MD; [Collaborator's Name], MD  
''[Department or Institution Name]''

<WRAP hide | 📝 Abstract>
[Brief summary of the case, including diagnosis, key interventions, and why it's relevant]
</WRAP>

===== 🩺 Case Presentation =====

[Patient age, weight, origin or referral source, presenting complaint]  
[Initial clinical assessment and context]  
[Key past medical history if relevant]

<WRAP hide | ⚡ Pending Tests / Imaging>
[Describe any tests (e.g., EEG, MRI, CT) that were pending or scheduled]
</WRAP>

===== 🧪 Clinical Findings =====

**🫁 Respiratory:**  
  * [Ventilation, oxygenation, saturation levels]  
  * [Relevant blood gas values]

**❤️ Cardiopulmonary:**  
  * [Heart rhythm, auscultation findings]

**🌡️ Temperature & Infection:**  
  * [Fever status, current antibiotics]

<WRAP hide | 🧫 Laboratory Data>
  * Diuresis: [normal / decreased]  
  * Renal function: [e.g., creatinine, urea]  
  * Hematology: [Hb, platelets, WBC]  
  * Electrolytes: [Na⁺, K⁺, etc.]  
  * Coagulation: [PT, INR, aPTT]
</WRAP>

<WRAP info round hide | 🧭 Management Plan>
  * [Consultations requested (e.g., Neurosurgery)]  
  * [Medications started or adjusted]  
  * [Surgical planning or scheduling]  
  * [Nutrition, sedation, or ventilation strategy]  
  * [Monitoring or follow-up orders]
</WRAP>

===== 🧠 Final Diagnosis (if applicable) =====

[Insert final diagnosis if confirmed (e.g., Cystic craniopharyngioma)]

===== 🏷️ Keywords =====

{{tag>case_report [diagnosis] [department] [keywords]}}