====== 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]] ---- ---- ====== 🧠 Case Report: [Insert concise case title here] ====== **👨‍⚕️ Authors:** [Your Name], MD; [Collaborator's Name], MD ''[Department or Institution Name]'' [Brief summary of the case, including diagnosis, key interventions, and why it's relevant] ===== 🩺 Case Presentation ===== [Patient age, weight, origin or referral source, presenting complaint] [Initial clinical assessment and context] [Key past medical history if relevant] [Describe any tests (e.g., EEG, MRI, CT) that were pending or scheduled] ===== 🧪 Clinical Findings ===== **🫁 Respiratory:** * [Ventilation, oxygenation, saturation levels] * [Relevant blood gas values] **❤️ Cardiopulmonary:** * [Heart rhythm, auscultation findings] **🌡️ Temperature & Infection:** * [Fever status, current antibiotics] * Diuresis: [normal / decreased] * Renal function: [e.g., creatinine, urea] * Hematology: [Hb, platelets, WBC] * Electrolytes: [Na⁺, K⁺, etc.] * Coagulation: [PT, INR, aPTT] * [Consultations requested (e.g., Neurosurgery)] * [Medications started or adjusted] * [Surgical planning or scheduling] * [Nutrition, sedation, or ventilation strategy] * [Monitoring or follow-up orders] ===== 🧠 Final Diagnosis (if applicable) ===== [Insert final diagnosis if confirmed (e.g., Cystic craniopharyngioma)] ===== 🏷️ Keywords ===== {{tag>case_report [diagnosis] [department] [keywords]}}