2018年 08月 13日

如何撰写英文医学病例报告标题及摘要?

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。

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。

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 ReportsOxford Medical Case ReportsBJR Case ReportsInternational 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。

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) 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, manwoman。下面给出几个比较好的标题例子:

  • An unusualpresentation 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

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 Huntington’s 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 Crohn’s 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 a poor positive predictive value.
  • Identifying and reporting anomalous enzymes is an important service the clinical lab technician can provide a clinician.
建议
  • 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 for patients who have risk factors identified.

 病例报告摘要示例

Example No 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 No. 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.].

其他参考链接

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