Posted on 12/01/07
A 47-year-old female from Hunterdon County, New Jersey, presents after having been bitten by a tick 3 days ago. She spends a great deal of time outdoors with her dogs and after coming inside and getting undressed, she noticed a small tick underneath her left shoulder blade. She is not sure how long the tick was attached but she doesn’t think it was more than 24 hours. Her husband was able to remove it, but she then went on to develop a small area of redness around the bite. She complains of pruritus at the site of the tick bite, but otherwise feels well. Her physical examination reveals a 1 centimeter area of erythema surrounding the site of the tick bite. There is no fluctuance or purulence at the site. Her vital signs are normal and the remainder of the physical examination is within normal limits.
What is the chance that this patient has Lyme disease?
A. She definitely has Lyme disease
B. She definitely does not have Lyme disease
C. Based upon her risk factors, she could have Lyme disease.
This patient has been bitten by a tick and there is a possibility that she could have contracted Lyme disease. Important factors to consider when trying to determine the risk of contracting Lyme Disease from a tick bite include:
1. The type of tick - Deer ticks, which are typically smaller than other varieties of tick are the primary carrier of [i]Borrelia burgdorferi[i], which is the bacteria that causes Lyme disease.
2. How long the tick was attached to the patient - There is a long period of time between the tick's first contact with its host and the potential time of infection. It takes between 36 to 72 hours of attachment for a tick to transmit Lyme disease.
3. Other risk factors - Patients who spend large amounts of time outdoors and who have pets are at higher risk for contracting Lyme disease.
4. Geographic locale - Patients who live in certain states (Massachusetts, Connecticut, Maine, New Hampshire, Rhode Island, New York, New Jersey, Pennsylvania, Delaware, Maryland, Minnesota, and Wisconsin) are more likely to get Lyme disease because of higher rates there.
The patient is terrified that she might have Lyme Disease, since her girlfriend had it and she was very sick. She demands both a test for it and immediate treatment. What should you do?
A. Prescribe doxycycline 100 mg twice daily for 21 days
B. Order Lyme serology
C. Both A and B
D. Reassure the patient that no testing or therapy is required, but to call if she develops any additional symptoms
Treatment of this patient should include reassurance, for several reasons. First of all, because the tick was only attached for about 24 hours, the likelihood of her developing Lyme disease is extremely low. Second of all, even if she were to have contracted Lyme disease, it would be so early in the disease that it would probably be impossible to confirm it, since it takes time for the antibody response to develop. Finally, the chance of toxicity or adverse effect from the antibiotic is much greater at this point than the potential benefit.
Symptoms of Lyme disease can vary widely and may include a rash at the site of the tick bite, cold or flu-like symptoms, arthritis, or other non-specific symptoms. Early localized Lyme disease, which is the first stage of the disease, causes a skin rash called erythema migrans (EM), and typically occurs within one month of the tick bite. Although EM occurs in approximately 90% of patients, some patients do not notice the rash, and they may go on to develop later stages of Lyme disease without knowing they have been infected.
Early disseminated disease occurs days to months after the tick bite and may present with rheumatologic, neurologic, or cardiac sequelae. Late Lyme disease occurs months to years after the onset of infection, and includes the most serious complications of Lyme arthritis and neuroborreliosis. There is effective treatment for all stages of Lyme disease, but some patients have post-Lyme disease symptoms, which the lay public has coined “chronic Lyme disease” but is more accurately referred to as “post-Lyme disease syndromes”.
Appropriate treatment for early Lyme disease involves oral antibiotic therapy with doxycyline, amoxicillin, or cefuroxime. Doxycycline is probably preferred, but should be avoided in pregnant patients and in those intending to sunbathe.
Therapy for early disseminated disease varies depending upon which type is present. Patients with asymptomatic disease and those with isolated facial nerve palsy can be treated for oral disease, while those with neurologic disease, such as meningitis, and cardiac disease, such as conduction system deficits, should be treated with intravenous therapy.
Treatment for late disease also varies based upon which type is present. Patients with early Lyme arthritis may be treated with oral therapy, while those with later Lyme arthritis (such as with recurrent disease) and any form of Lyme neurologic disease may be treated with intravenous antibiotics.
The patient is not happy when you try to reassure her. What should you do?
A. Cave in and give her the antibiotic
B. Give her a slip for a blood test
C. Reassure her once again
D. Refer her to a psychiatrist
As stated above, reassurance is the best thing to do at this point. If the patient’s concerns are so severe as to seem pathologic, then perhaps further investigation for anxiety disorder might be warranted, but referring her to a psychiatrist at this point is not indicated.[i][/i]
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This set of guidelines provides both instructions and a template for the writing of case reports for publication. You might want to skip forward and take a quick look at the template now, as we will be using it as the basis for your own case study later on. While the guidelines and template contain much detail, your finished case study should be only 500 to 1,500 words in length. Therefore, you will need to write efficiently and avoid unnecessarily flowery language.
These guidelines for the writing of case studies are designed to be consistent with the “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” referenced elsewhere in the JCCA instructions to authors.
After this brief introduction, the guidelines below will follow the headings of our template. Hence, it is possible to work section by section through the template to quickly produce a first draft of your study. To begin with, however, you must have a clear sense of the value of the study which you wish to describe. Therefore, before beginning to write the study itself, you should gather all of the materials relevant to the case – clinical notes, lab reports, x-rays etc. – and form a clear picture of the story that you wish to share with your profession. At the most superficial level, you may want to ask yourself “What is interesting about this case?” Keep your answer in mind as your write, because sometimes we become lost in our writing and forget the message that we want to convey.
Another important general rule for writing case studies is to stick to the facts. A case study should be a fairly modest description of what actually happened. Speculation about underlying mechanisms of the disease process or treatment should be restrained. Field practitioners and students are seldom well-prepared to discuss physiology or pathology. This is best left to experts in those fields. The thing of greatest value that you can provide to your colleagues is an honest record of clinical events.
Finally, remember that a case study is primarily a chronicle of a patient’s progress, not a story about chiropractic. Editorial or promotional remarks do not belong in a case study, no matter how great our enthusiasm. It is best to simply tell the story and let the outcome speak for itself. With these points in mind, let’s begin the process of writing the case study:
Title: The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet. They may have to decide, just by looking at the title, whether or not they want to access the full article. A title which is vague or non-specific may not attract their attention. Thus, our title should contain the phrase “case study,” “case report” or “case series” as is appropriate to the contents. The two most common formats of titles are nominal and compound. A nominal title is a single phrase, for example “A case study of hypertension which responded to spinal manipulation.” A compound title consists of two phrases in succession, for example “Response of hypertension to spinal manipulation: a case study.” Keep in mind that titles of articles in leading journals average between 8 and 9 words in length.
Other contents for the title page should be as in the general JCCA instructions to authors. Remember that for a case study, we would not expect to have more than one or two authors. In order to be listed as an author, a person must have an intellectual stake in the writing – at the very least they must be able to explain and even defend the article. Someone who has only provided technical assistance, as valuable as that may be, may be acknowledged at the end of the article, but would not be listed as an author. Contact information – either home or institutional – should be provided for each author along with the authors’ academic qualifications. If there is more than one author, one author must be identified as the corresponding author – the person whom people should contact if they have questions or comments about the study.
Key words: Provide key words under which the article will be listed. These are the words which would be used when searching for the article using a search engine such as Medline. When practical, we should choose key words from a standard list of keywords, such as MeSH (Medical subject headings). A copy of MeSH is available in most libraries. If we can’t access a copy and we want to make sure that our keywords are included in the MeSH library, we can visit this address: http://www.ncbi.nlm.nih.gov:80/entrez/meshbrowser.cgi
Abstract: Abstracts generally follow one of two styles, narrative or structured.
A narrative abstract consists of a short version of the whole paper. There are no headings within the narrative abstract. The author simply tries to summarize the paper into a story which flows logically.
A structured abstract uses subheadings. Structured abstracts are becoming more popular for basic scientific and clinical studies, since they standardize the abstract and ensure that certain information is included. This is very useful for readers who search for articles on the internet. Often the abstract is displayed by a search engine, and on the basis of the abstract the reader will decide whether or not to download the full article (which may require payment of a fee). With a structured abstract, the reader is more likely to be given the information which they need to decide whether to go on to the full article, and so this style is encouraged. The JCCA recommends the use of structured abstracts for case studies.
Introduction: This consists of one or two sentences to describe the context of the case and summarize the entire article.
Case presentation: Several sentences describe the history and results of any examinations performed. The working diagnosis and management of the case are described.
Management and Outcome: Simply describe the course of the patient’s complaint. Where possible, make reference to any outcome measures which you used to objectively demonstrate how the patient’s condition evolved through the course of management.
Discussion: Synthesize the foregoing subsections and explain both correlations and apparent inconsistencies. If appropriate to the case, within one or two sentences describe the lessons to be learned.
Introduction: At the beginning of these guidelines we suggested that we need to have a clear idea of what is particularly interesting about the case we want to describe. The introduction is where we convey this to the reader. It is useful to begin by placing the study in a historical or social context. If similar cases have been reported previously, we describe them briefly. If there is something especially challenging about the diagnosis or management of the condition that we are describing, now is our chance to bring that out. Each time we refer to a previous study, we cite the reference (usually at the end of the sentence). Our introduction doesn’t need to be more than a few paragraphs long, and our objective is to have the reader understand clearly, but in a general sense, why it is useful for them to be reading about this case.
Case presentation: This is the part of the paper in which we introduce the raw data. First, we describe the complaint that brought the patient to us. It is often useful to use the patient’s own words. Next, we introduce the important information that we obtained from our history-taking. We don’t need to include every detail – just the information that helped us to settle on our diagnosis. Also, we should try to present patient information in a narrative form – full sentences which efficiently summarize the results of our questioning. In our own practice, the history usually leads to a differential diagnosis – a short list of the most likely diseases or disorders underlying the patient’s symptoms. We may or may not choose to include this list at the end of this section of the case presentation.
The next step is to describe the results of our clinical examination. Again, we should write in an efficient narrative style, restricting ourselves to the relevant information. It is not necessary to include every detail in our clinical notes.
If we are using a named orthopedic or neurological test, it is best to both name and describe the test (since some people may know the test by a different name). Also, we should describe the actual results, since not all readers will have the same understanding of what constitutes a “positive” or “negative” result.
X-rays or other images are only helpful if they are clear enough to be easily reproduced and if they are accompanied by a legend. Be sure that any information that might identify a patient is removed before the image is submitted.
At this point, or at the beginning of the next section, we will want to present our working diagnosis or clinical impression of the patient.
Management and Outcome: In this section, we should clearly describe the plan for care, as well as the care which was actually provided, and the outcome.
It is useful for the reader to know how long the patient was under care and how many times they were treated. Additionally, we should be as specific as possible in describing the treatment that we used. It does not help the reader to simply say that the patient received “chiropractic care.” Exactly what treatment did we use? If we used spinal manipulation, it is best to name the technique, if a common name exists, and also to describe the manipulation. Remember that our case study may be read by people who are not familiar with spinal manipulation, and, even within chiropractic circles, nomenclature for technique is not well standardized.
We may want to include the patient’s own reports of improvement or worsening. However, whenever possible we should try to use a well-validated method of measuring their improvement. For case studies, it may be possible to use data from visual analogue scales (VAS) for pain, or a journal of medication usage.
It is useful to include in this section an indication of how and why treatment finished. Did we decide to terminate care, and if so, why? Did the patient withdraw from care or did we refer them to another practitioner?
Discussion: In this section we may want to identify any questions that the case raises. It is not our duty to provide a complete physiological explanation for everything that we observed. This is usually impossible. Nor should we feel obligated to list or generate all of the possible hypotheses that might explain the course of the patient’s condition. If there is a well established item of physiology or pathology which illuminates the case, we certainly include it, but remember that we are writing what is primarily a clinical chronicle, not a basic scientific paper. Finally, we summarize the lessons learned from this case.
Acknowledgments: If someone provided assistance with the preparation of the case study, we thank them briefly. It is neither necessary nor conventional to thank the patient (although we appreciate what they have taught us). It would generally be regarded as excessive and inappropriate to thank others, such as teachers or colleagues who did not directly participate in preparation of the paper.
References: References should be listed as described elsewhere in the instructions to authors. Only use references that you have read and understood, and actually used to support the case study. Do not use more than approximately 15 references without some clear justification. Try to avoid using textbooks as references, since it is assumed that most readers would already have this information. Also, do not refer to personal communication, since readers have no way of checking this information.
A popular search engine for English-language references is Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi
Legends: If we used any tables, figures or photographs, they should be accompanied by a succinct explanation. A good rule for graphs is that they should contain sufficient information to be generally decipherable without reference to a legend.
Tables, figures and photographs should be included at the end of the manuscript.
Permissions: If any tables, figures or photographs, or substantial quotations, have been borrowed from other publications, we must include a letter of permission from the publisher. Also, if we use any photographs which might identify a patient, we will need their written permission.
In addition, patient consent to publish the case report is also required.