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 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。

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 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.].

其他资源

• How to Compose a Journal Submission Cover Letter (Wordvice/YouTube)
• 期刊投稿信(cover letter)要怎么写？(Wordvice)
• 40 Useful Words and Phrases for Top-Notch Essays (Oxford Royale Academy)
• 如何替换论文中的动词，让文章更吸引人? (Wordvice)
• Essential Academic Writing Words and Phrases (My English Teacher.eu)
• Academic Vocabulary, Useful Phrases for Academic Writing and Research Paper Writing (Research Gate)

需要英文润色，英语润色，就找Wordvice。
| 资源博客 | 学术论文润色 | 学术论文翻译 | 期刊论文润色 | 毕业论文润色 | 论文摘要润色 | 服务费用 | FAQ |