Problem description:

The teacher asked us to write medical records, and we couldn't start the first time.

I hope there are medical records for reference, preferably common diseases.

Thank you very much.

Analysis:

Case report is a common genre of medical papers. This paper attempts to provide first-hand perceptual information about the manifestation, mechanism, diagnosis and treatment of the disease for medical reports by recording and describing one or two vivid cases. Case report is a common column in medical journals. Previous case reports mostly reported some new cases discovered for the first time, such as AIDS and legionnaires' disease, which were discovered through case reports. However, with the passage of time, the case report papers have mainly focused on the special clinical manifestations of known diseases, the new findings of diagnostic methods such as imaging and laboratory, the special clinical outcome of diseases, and the special experiences and lessons in clinical diagnosis and treatment. Typical case reports give readers a profound perceptual knowledge by vividly describing the image of the disease, so that the abstract general disease manifestations and diagnosis and treatment process have concrete image content, which is convenient for clinicians to further grasp the characteristics and essence of the disease in theory.

Clinicians sometimes meet some patients whose clinical manifestations are beyond their own knowledge and cannot be classified according to existing knowledge. This case may be a rare case. Of course, to determine whether a case is rare, we need to search the literature database carefully and comprehensively to see if anyone else has reported it. Rare cases may be caused by special iron tissue lesions or biochemical disorders. Therefore, whenever we encounter special and rare cases, we should try our best to use all kinds of modern means to carry out detection and research, and strive to further clarify the pathogenesis of the disease.

If two or more rare diseases coexist in the same patient, or a syndrome and a rare symptom coexist in the same patient, it may indicate that there is some correlation between them, and even one disease may be caused by another. Such case reports should have sufficient laboratory and imaging evidence or pathological evidence to support the mechanism and causality of comorbidity.

The abnormal clinical manifestations or prognosis of some cases may provide new clues for pathology, etiology or treatment mechanism, and provide basis for further prospective research. These abnormal manifestations or special outcomes of diseases can be caused by drugs or other intervention measures, or they can be unique manifestations of diseases. This kind of case report should have enough evidence of clinical examination and various examinations to show the abnormal performance and the certainty of special prognosis.

Case reports are generally divided into title, author's name, unit, preface, case introduction, discussion, references and other parts.

The title of the case report requires that the name of the disease or new method and the number of cases be written directly, closely following the content of the paper, so that readers can have a general understanding of the content of the paper after reading.

The preface of the case report is dispensable, as short as possible, just a few words.

The case introduction should clearly explain the necessary course details, including the onset, development, prognosis and follow-up results of the patient. Never copy the original medical records, and avoid using all kinds of non-objective, doubtful or speculative statements. As the case report is a rare or special case, the symptoms, signs, examination results and treatment methods with special significance should be described in detail, and the key points should be highlighted. When describing the medical history, it is necessary to explain clearly the onset time, chief complaint and course of disease. For recurrent diseases and congenital diseases, we should pay attention to past history and family history. Trauma patients should write down their injuries. Laboratory examination and imaging examination usually only list positive and necessary negative results. Other irrelevant negative results can be omitted. Pay attention to the comparison before and after the positive results with special significance. Surgical treatment should explain the name of the operation, preoperative treatment, intraoperative findings, postoperative treatment and postoperative response. The treatment results should not only explain the curative effect, but also explain the side effects.

The content of the discussion should be closely related to the case, and generally necessary explanations can be made around the reported case to clarify the author's point of view or put forward new points of view. There should be enough arguments in the discussion to explain the rarity and particularity of this case.