Punctuation, Grammar, Syntax, use of AMA style 30
Thoughts are organized and flow logically 15
Case Presentation 45
100 total points
Case Report Worksheet
(Content of a Case Report)
Author Heidi Aleman- Ortega
1) Abstract Clinical question/problem Analysis of literature review Summary
2) Case history/report
A. Description of patient: 76 y/o male 2 day s/p left thoracotomy for extraction of abandoned epi- cardial ICD patch And right venticulotomy for extraction of two ventricular leads one abandoned and the second infected and right trans venous extraction of two atrial leads, again one abandoned and one infected. Temporary pacemaker wires in place. Waiting surgery in am to replace pacing dual chamber ICD system.
B. History of presenting condition Upon walking in to exam patient and obtain consent for case in am. Found patient of floor complain of intractable pain.
C. Physical exam Frail, small framed man weighing 65 kilograms, 170 centimeters height history of multiple laminectomies and lumbar fusion T6-L5, diagnosed with failed back syndrome on long term fentanyl patch and oral pain medications which had been discontinued during hospitalization
D. Relevant medications
E. Initial diagnosis and treatment Patient transferred to ICU for bolus of fentanyl and Dexmedetomidine infusion
F. Expected outcome
G. Actual outcome
3) Literature search A. MEDLINE/other database
B. Search terms
C. Results of search (# relevant, citations, what you learned)
4) Discussion (significance, why you’re writing this)
A. Relevant literature
C. Diagnostic process/course of illness i. Table of diagnostic process ii. Figures, photographs, imaging
i. Drug-drug interactions
ii. Drug-condition interactions
iii. Other conflicting outcomes/observations
5) Conclusions/recommendations (lesson learned)
Szumita P, Baroletti S, Anger K, Wechsler M. Sedation and analgesia in the intensive care unit: evaluating the role of dexmedetomidine. American Journal Of Health-System Pharmacy: AJHP: Official Journal Of The American Society Of Health-System Pharmacists [serial online]. January 1, 2007;64(1):37-44. Available from: MEDLINE Complete, Ipswich, MA. Accessed October 11, 2015
Hilliard N, Brown S, Mitchinson S. A case report of dexmedetomidine used to treat intractable pain and delirium in a tertiary palliative care unit. Palliative Medicine [serial online]. March 2015;29(3):278-281. Available from: MEDLINE Complete, Ipswich, MA. Accessed October 11, 2015.
Jain G, Bansal P, Ahmad B, Singh D, Yadav G. Effect of the perioperative infusion of dexmedetomidine on chronic pain after breast surgery. Indian Journal Of Palliative Care [serial online]. January 2012;18(1):45-51. Available from: MEDLINE Complete, Ipswich, MA. Accessed October 11, 2015
Unlugenc H, Gunduz M, Guler T, Yagmur O, Isik G. The effect of pre-anaesthetic administration of intravenous dexmedetomidine on postoperative pain in patients receiving patient-controlled morphine. European Journal Of Anaesthesiology [serial online]. May 2005;22(5):386-391. Available from: MEDLINE Complete, Ipswich, MA. Accessed October 11, 2015.
Roberts S, Wozencraft C, Coyne P, Smith T. Dexmedetomidine as an adjuvant analgesic for intractable cancer pain. Journal Of Palliative Medicine [serial online]. March 2011;14(3):371-373. Available from: MEDLINE Complete, Ipswich, MA. Accessed October 11, 2015.
Abstract: Explanations of the clinical questions or problems are addressed in the Case report. In addition, a statement summarizing why this case is unusual and noteworthy should be included.
Introduction: Justification as to why the case is worthy of discussion. Relevant background information obtained through a review of the literature.
Case Presentation Introduction of patient and history of present illness is presented. In chronological order. Only pertinent findings from the physical exam and laboratory/imaging studies are included, as are normal values for less commonly ordered tests.
Discussion Address any contradictory evidence. Emphasize the importance and educational value of the cases.
Summary State the take-home message you may also address what you would have done differently the next time. Provide recommendations to other clinicians and researchers and consider suggesting possibilities for further study