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Guidelines for writing patient case report manuscriptsGuidelines for writing patient case report manuscripts (The following checklist is comprehensive; some items may not apply to all types of case reports.) Patient case presentation Describe the case in a narrative form. Provide patient demographics (age, sex, height, weight, race, occupation). Provide patient identifiers (date of birth, initials). Describe the patient’s complaint. List the patient’s present illness. List the patient’s medical history. List the patient’s family history. List the patient’s social history. List the patient’s medication history before admission and throughout the case report. Ensure that the medication history includes: herbals, vaccines, depot injections, and nonprescription medications List each drug’s name, strength, dosage form, route, and dates of administration. Verify the patient’s medication adherence. List the patient’s drug allergy status, including the name of the drug (brand or generic) and the date and type of reaction. List the patient’s adverse drug reaction history and the dates of the reaction. Provide the patient’s dietary history. Provide pertinent findings on physical examination. Provide pertinent laboratory findings that support the case. List the completed diagnostic procedures that are pertinent and support the case. Paraphrase the results of the diagnostic procedures. Provide photographs of histopathology, roentgenograms, electrocardiograms, skin manifestations, or anatomy as they relate to the case. Obtain permission from the patient to use the patient’s photographs, or follow institutional guidelines. Provide the patient’s events in chronological order.
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