Case report（三）如何写并成功发表，通过案例分享给临床科研者们一点启示

五姨的第二天！

上周给大家介绍了病例的基本情况介绍在写作的时候需要注意一些什么，汇总了写作的要点，并通过实例进行了解析。有需要的搜标题回看：Case report（二）如何写并成功发表，通过案例分享给临床科研者们一点启示

如何写好一篇case report并成功发表，通过案例分享给临床科研者们一点启示Part1。今天，我们再对病程、检查和诊断部分的写作进行一个详细的剖析。

现阶段疫情又来势汹汹，袭击了全国各地，我国当前面临的疫情形势十分严峻，大家在进行临床工作的时候挖掘下周边的病例是否就可以写成case发表一下呢？

2 病程

主要说明典型的症状、并发症、诊断与治疗过程，避免无关的材料。

例2-1：出自Ilgüy D, Ilgüy M, Fisekcioglu E, Bayirli G (2014) Detection of jaw and root fractures using cone beam computed tomography: a case report.

The patient was initially examined by her dentist, who diagnosed a fracture in the right mandibular canine region with CT (初步诊断). Upon clinical examination, the right mandibular canine did not respond to an electric pulp sensitivity test or to a cold sensitivity test at 50˚C. The tooth was not mobile, but was sensitive to percussion. The adjacent teeth were asymptomatic and responded normally to cold and electric pulp tests.

解析：介绍整个疾病的诊断过程及发现。最初由牙医通过CT诊断为右下颌犬区域骨折，随后临床检测发现右下颌犬区域对电浆敏感性测试或冷敏感性试验无反应。牙齿无松动，但对叩诊敏感，相邻牙齿无任何症状且对电浆敏感性测试或冷敏感性试验有反应。

例2-2：出自Sjogren PP, Banerji N, Batts KP, Graczyk MJ, Dunn DH (2013) Rare presentation of a gastrointestinal stromal tumor with spontaneous esophageal perforation: A case report. International journal of surgery case reports 4 (7):636-639.

After resuscitation and stabilization, a diagnostic chest radiograph revealed a moderate right-sided pleural effusion that was drained via tube thoracostomy with an output of 1200 mL serosanguineous fluid. A subsequent esophagram demonstrated a perforation proximal to an elongated stricture in the distal esophagus.

    解析：介绍诊断过程。首先胸片显示右侧胸腔积液，经管状胸廓造口术引流后，随后的食管x线片发现食道远端有细长的穿孔现象。

3 检查与诊断

主要是说明特殊的检查方法及结果，这个也是病例报告与其他文章的不同之处，即方法和结果一起描述，表示某种方法得出某种结果。

例3-1：出自Gugssa SA, Johnston JC (2012) Syphilitic aortic aneurysm with spastic paraparesis: A novel presentation and review of the literature. Journal of the neurological sciences 323 (1):241-244.

On general examination (一般检查), he had systolic hypertension with wide pulse pressure and a grade II early diastolic murmur at the left lower sternal border. Breath sounds (呼吸音检查) were clear bilaterally. There were no carotid bruits. Abdominal examination (腹部检查) was normal to auscultation and palpation. Femoral, tibialis posterior and dorsalis pedis pulses were normal.

    解析：本段介绍一些初步的常规检查检查及判断，患者有收缩性高血压，呼吸音清晰，无颈动脉杂音，腹部听诊及触诊也是正常的，另外股骨、胫后和足背动脉搏动也是正常的。这部分写作要注意的是，并非所有做过的常规检查都要写，关键是看文章所介绍疾病，与其相关的检查必须描述。

例3-2：出自Toriyama A, Ishida M, Amano T, Nakagawa T, Kaku S, Iwai M, Yoshida K, Kagotani A, Takahashi K, Murakami T (2013) Leiomyomatosis peritonealis disseminata coexisting with endometriosis within the same lesions: a case report with review of the literature. Int J Clin Exp Pathol 6 (12):2949-2954.

Physical examination (体格检查) revealed an immovable tumor in her abdominal cavity. Laboratory tests (实验室检查) demonstrated elevated serum CA125 (567 U/mL; range <34) and CA19-9 (193 U/mL; range <36) levels. Contrast enhanced computed tomography (CT扫描检查) showed a containing solid area with enhancement in the right ovary and multiple small nodules with enhancement in her abdominal cavity. Intraoperative examination (术中检查) revealed that the right ovarian tumor, measuring 12 cm in diameter, was strongly adhered to the cecum, and innumerable small nodular lesions, measuring 1 to 30 mm in diameter, were present in the mesentery, omentum, peritoneum, Douglas’s pouch, and serosal surface of the small intestine, large intestine, and rectum. Histopathological examination (组织病理学检查) of the resected disseminated nodules revealed well-circumscribed multiple nodular lesions, measuring 1 to 25 mm in diameter, in the peritoneum。

解析：本段对疾病的诊断方法及结果做了详细描述。首先体格检查结果显示腹腔有肿瘤，实验室血液检查发现血清中疾病相关因子的水平升高。然后，CT检测发现腹腔有囊性病变。随后的手术中检测发现右卵巢肿瘤粘附在盲肠上，且在其他肠中伴有无数的结节状病灶。最终的组织病理学检查病灶发现弥散性的结节。疾病的检查和诊断这部分是文章重点，需要详细描述，要让读者明白整个过程，可以为其他临床医生提供一些借鉴和指导。

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