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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Case study: 33-year-old female presents with chronic sob and cough.

Sandeep Sharma ; Muhammad F. Hashmi ; Deepa Rawat .

Affiliations

Last Update: February 20, 2023 .

Case Presentation

History of Present Illness: A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound (9 kg) intentional weight loss over the past year. She denies camping, spelunking, or hunting activities. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She admits a cough, shortness of breath, and shortness of breath on exertion.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She denies alcohol and illicit drug use. She is in a married, monogamous relationship and has three children aged 15 months to 5 years. She is employed in a cookie bakery. She has two pet doves. She traveled to Mexico for a one-week vacation one year ago.

Allergies: No known medicine, food, or environmental allergies.

Past Medical History: Hypertension

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10 mg by mouth every day

Physical Exam:

Vitals: Temperature, 97.8 F; heart rate 88; respiratory rate, 22; blood pressure 130/86; body mass index, 28

General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress causing her to stop mid-sentence.

Respiratory: She has diffuse rales and mild wheezing; tachypneic.

Cardiovascular: She has a regular rate and rhythm with no murmurs, rubs, or gallops.

Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

Initial Evaluation

Laboratory Studies: Initial work-up from the emergency department revealed pancytopenia with a platelet count of 74,000 per mm3; hemoglobin, 8.3 g per and mild transaminase elevation, AST 90 and ALT 112. Blood cultures were drawn and currently negative for bacterial growth or Gram staining.

Chest X-ray

Impression: Mild interstitial pneumonitis

Differential Diagnosis
Aspiration pneumonitis and pneumonia
Bacterial pneumonia
Immunodeficiency state and Pneumocystis jiroveci pneumonia
Carcinoid lung tumors
Tuberculosis
Viral pneumonia
Chlamydial pneumonia
Coccidioidomycosis and valley fever
Recurrent Legionella pneumonia
Mediastinal cysts
Mediastinal lymphoma
Recurrent mycoplasma infection
Pancoast syndrome
Pneumococcal infection
Sarcoidosis
Small cell lung cancer
Aspergillosis
Blastomycosis
Histoplasmosis
Actinomycosis
Confirmatory Evaluation

CT of the chest was performed to further the pulmonary diagnosis; it showed a diffuse centrilobular micronodular pattern without focal consolidation.

On finding pulmonary consolidation on the CT of the chest, a pulmonary consultation was obtained. Further history was taken, which revealed that she has two pet doves. As this was her third day of broad-spectrum antibiotics for a bacterial infection and she was not getting better, it was decided to perform diagnostic bronchoscopy of the lungs with bronchoalveolar lavage to look for any atypical or rare infections and to rule out malignancy (Image 1).

Bronchoalveolar lavage returned with a fluid that was cloudy and muddy in appearance. There was no bleeding. Cytology showed Histoplasma capsulatum .

Based on the bronchoscopic findings, a diagnosis of acute pulmonary histoplasmosis in an immunocompetent patient was made.

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe, or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks total. The response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving work of respiration. [1] [2] [3]

Histoplasmosis, also known as Darling disease, Ohio valley disease, reticuloendotheliosis, caver's disease, and spelunker's lung, is a disease caused by the dimorphic fungi Histoplasma capsulatum native to the Ohio, Missouri, and Mississippi River valleys of the United States. The two phases of Histoplasma are the mycelial phase and the yeast phase.

Etiology/Pathophysiology

Histoplasmosis is caused by inhaling the microconidia of Histoplasma spp. fungus into the lungs. The mycelial phase is present at ambient temperature in the environment, and upon exposure to 37 C, such as in a host’s lungs, it changes into budding yeast cells. This transition is an important determinant in the establishment of infection. Inhalation from soil is a major route of transmission leading to infection. Human-to-human transmission has not been reported. Infected individuals may harbor many yeast-forming colonies chronically, which remain viable for years after initial inoculation. The finding that individuals who have moved or traveled from endemic to non-endemic areas may exhibit a reactivated infection after many months to years supports this long-term viability. However, the precise mechanism of reactivation in chronic carriers remains unknown.

Infection ranges from an asymptomatic illness to a life-threatening disease, depending on the host’s immunological status, fungal inoculum size, and other factors. Histoplasma spp. have grown particularly well in organic matter enriched with bird or bat excrement, leading to the association that spelunking in bat-feces-rich caves increases the risk of infection. Likewise, ownership of pet birds increases the rate of inoculation. In our case, the patient did travel outside of Nebraska within the last year and owned two birds; these are her primary increased risk factors. [4]

Non-immunocompromised patients present with a self-limited respiratory infection. However, the infection in immunocompromised hosts disseminated histoplasmosis progresses very aggressively. Within a few days, histoplasmosis can reach a fatality rate of 100% if not treated aggressively and appropriately. Pulmonary histoplasmosis may progress to a systemic infection. Like its pulmonary counterpart, the disseminated infection is related to exposure to soil containing infectious yeast. The disseminated disease progresses more slowly in immunocompetent hosts compared to immunocompromised hosts. However, if the infection is not treated, fatality rates are similar. The pathophysiology for disseminated disease is that once inhaled, Histoplasma yeast are ingested by macrophages. The macrophages travel into the lymphatic system where the disease, if not contained, spreads to different organs in a linear fashion following the lymphatic system and ultimately into the systemic circulation. Once this occurs, a full spectrum of disease is possible. Inside the macrophage, this fungus is contained in a phagosome. It requires thiamine for continued development and growth and will consume systemic thiamine. In immunocompetent hosts, strong cellular immunity, including macrophages, epithelial, and lymphocytes, surround the yeast buds to keep infection localized. Eventually, it will become calcified as granulomatous tissue. In immunocompromised hosts, the organisms disseminate to the reticuloendothelial system, leading to progressive disseminated histoplasmosis. [5] [6]

Symptoms of infection typically begin to show within three to17 days. Immunocompetent individuals often have clinically silent manifestations with no apparent ill effects. The acute phase of infection presents as nonspecific respiratory symptoms, including cough and flu. A chest x-ray is read as normal in 40% to 70% of cases. Chronic infection can resemble tuberculosis with granulomatous changes or cavitation. The disseminated illness can lead to hepatosplenomegaly, adrenal enlargement, and lymphadenopathy. The infected sites usually calcify as they heal. Histoplasmosis is one of the most common causes of mediastinitis. Presentation of the disease may vary as any other organ in the body may be affected by the disseminated infection. [7]

The clinical presentation of the disease has a wide-spectrum presentation which makes diagnosis difficult. The mild pulmonary illness may appear as a flu-like illness. The severe form includes chronic pulmonary manifestation, which may occur in the presence of underlying lung disease. The disseminated form is characterized by the spread of the organism to extrapulmonary sites with proportional findings on imaging or laboratory studies. The Gold standard for establishing the diagnosis of histoplasmosis is through culturing the organism. However, diagnosis can be established by histological analysis of samples containing the organism taken from infected organs. It can be diagnosed by antigen detection in blood or urine, PCR, or enzyme-linked immunosorbent assay. The diagnosis also can be made by testing for antibodies again the fungus. [8]

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks. The patient's response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving the work of respiration.

The disseminated disease requires similar systemic antifungal therapy to pulmonary infection. Additionally, procedural intervention may be necessary, depending on the site of dissemination, to include thoracentesis, pericardiocentesis, or abdominocentesis. Ocular involvement requires steroid treatment additions and necessitates ophthalmology consultation. In pericarditis patients, antifungals are contraindicated because the subsequent inflammatory reaction from therapy would worsen pericarditis.

Patients may necessitate intensive care unit placement dependent on their respiratory status, as they may pose a risk for rapid decompensation. Should this occur, respiratory support is necessary, including non-invasive BiPAP or invasive mechanical intubation. Surgical interventions are rarely warranted; however, bronchoscopy is useful as both a diagnostic measure to collect sputum samples from the lung and therapeutic to clear excess secretions from the alveoli. Patients are at risk for developing a coexistent bacterial infection, and appropriate antibiotics should be considered after 2 to 4 months of known infection if symptoms are still present. [9]

Prognosis

If not treated appropriately and in a timely fashion, the disease can be fatal, and complications will arise, such as recurrent pneumonia leading to respiratory failure, superior vena cava syndrome, fibrosing mediastinitis, pulmonary vessel obstruction leading to pulmonary hypertension and right-sided heart failure, and progressive fibrosis of lymph nodes. Acute pulmonary histoplasmosis usually has a good outcome on symptomatic therapy alone, with 90% of patients being asymptomatic. Disseminated histoplasmosis, if untreated, results in death within 2 to 24 months. Overall, there is a relapse rate of 50% in acute disseminated histoplasmosis. In chronic treatment, however, this relapse rate decreases to 10% to 20%. Death is imminent without treatment.

Pearls of Wisdom

While illnesses such as pneumonia are more prevalent, it is important to keep in mind that more rare diseases are always possible. Keeping in mind that every infiltrates on a chest X-ray or chest CT is not guaranteed to be simple pneumonia. Key information to remember is that if the patient is not improving under optimal therapy for a condition, the working diagnosis is either wrong or the treatment modality chosen by the physician is wrong and should be adjusted. When this occurs, it is essential to collect a more detailed history and refer the patient for appropriate consultation with a pulmonologist or infectious disease specialist. Doing so, in this case, yielded workup with bronchoalveolar lavage and microscopic evaluation. Microscopy is invaluable for definitively diagnosing a pulmonary consolidation as exemplified here where the results showed small, budding, intracellular yeast in tissue sized 2 to 5 microns that were readily apparent on hematoxylin and eosin staining and minimal, normal flora bacterial growth.

Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

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Histoplasma Contributed by Sandeep Sharma, MD

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Sharma S, Hashmi MF, Rawat D. Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Medical Studies

How to Write a Medical Case Study Report

Last Updated: July 5, 2022 Fact Checked

This article was medically reviewed by Mark Ziats, MD, PhD and by wikiHow staff writer, Jennifer Mueller, JD . Dr. Mark Ziats is an Internal Medicine Physician, Scientist, Entrepreneur, and the Medical Director of xBiotech. With over five years of experience, he specializes in biotechnology, genomics, and medical devices. He earned a Doctor of Medicine degree from Baylor College of Medicine, a Ph.D. in Genetics from the University of Cambridge, and a BS in Biochemistry and Chemistry from Clemson University. He also completed the INNoVATE Program in Biotechnology Entrepreneurship at The Johns Hopkins University - Carey Business School. Dr. Ziats is board certified by the American Board of Internal Medicine. There are 16 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 186,057 times.

You've encountered an interesting and unusual case on your rounds, and a colleague or supervising physician says, "Why don't you write up a case study report?" If you've never written one before, that might sound intimidating, but it's a great way to get started in medical writing. Case studies always follow a standard structure and format, so the writing is very formulaic once you get the hang of it. Read on for a step-by-step guide to writing your first case study report.

What is a case study report?

Step 1 A case study report is an academic publication describing an unusual or unique case.

Medical students or residents typically do the bulk of the writing of the report. If you're just starting your medical career, a case study report is a great way to get a publication under your belt. [2] X Research source

Step 2 Your report discusses the case presented by one patient.

If the patient is a minor or is incapable of giving informed consent, get consent from their parents or closest relative. [4] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source
Your hospital likely has specific consent forms to use. Ask your supervising physician if you're not sure where to get one.
Some journals also have their own consent form. Check your target journal's author or submission information to make sure. [5] X Research source

How is a case study report structured?

Step 1 A typical report consists of an abstract, intro, case description, discussion, and conclusion.

Even though the introduction is the first part of a case study report, doctors typically write it last. You'll have a better idea of how to introduce your case study to readers after you've written it.
Your abstract comes at the top, before the introduction, and provides a brief summary of the entire report. Unless your case study is published in an open-access journal, the abstract is the only part of the article many readers will see.

Step 2 Check your target journal for possible variations.

Many journals offer templates and checklists you can use to make sure your case study includes everything necessary and is formatted properly—take advantage of these! Some journals, such as BMJ Case Reports , require all case studies submitted to use their templates.

Drafting Your Medical Case Study Report

Step 1 Pull all of the hospital records for the case.

Patient description
Chronological case history
Physical exam results
Results of any pathological tests, imaging, or other investigations
Treatment plan
Expected outcome of treatment
Actual outcome of treatment

Step 2 Write a draft of the case presentation.

Why the patient sought medical help (you can even use their own words)
Important information that helped you settle on your diagnosis
The results of your clinical examination, including diagnostic tests and their results, along with any helpful images
A description of the treatment plan
The outcome, including how and why treatment ended and how long the patient was under your care [11] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

Step 3 Research the existing literature on the patient's condition and treatment.

You will need references to back up symptoms of the condition, common treatment, and the expected outcome of that common treatment.
Use your research to paint a picture of the usual case of a patient with a similar condition—it'll help you show how unusual and different your patient's case is.
Generally, aim for around 20 references—no fewer than 15, but no more than 25. [13] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

Step 4 Write a section discussing the case in light of your research.

Close your discussion section with a summary of the lessons learned from the case and why it's significant to consider when treating similar cases in the future.
Outline any open questions that remain. You might also provide suggestions for future research.

Step 5 Complete your introduction and conclusion after you've written the body.

In your conclusion, you might also give suggestions or recommendations to readers based on what you learned as a result of the case.
Some journals don't want a separate conclusion section. If that's the case for one of your target journals, just move this paragraph to the end of your discussion section.

Polishing Your Report for Submission to Publishers

Step 1 Come up with a title for your case study.

Most titles are fewer than 10 words long and include the name of the disease or condition treated.
You might also include the treatment used and whether the outcome was successful. When deciding what to include, think about the reason you wrote the case study in the first place and why you think it's important for other clinicians to read.

Step 2 Identify the authors of the report on the title page.

Made a significant intellectual contribution to the case study report
Was involved in the medical care of the patient reported
Can explain and defend the data presented in the report
Has approved the final manuscript before submission for publication

Step 3 Write an abstract summarizing the entire article.

Keep in mind that the abstract is not just going to be the first thing people read—it will often be the only thing people read. Make sure that if someone is going to walk away having only read the abstract, they'll still get the same message they would have if they read the whole thing.
There are 2 basic types of abstract: narrative and structured. A narrative abstract is a single paragraph written in narrative prose. A structured abstract includes headings that correspond with the sections of the paper, then a brief summary of each section. Use the format preferred by your target journal.

Step 4 Choose keywords that will help readers find your case study.

Look for keywords that are relevant to your field or sub-field and directly related to the content of your article, such as the name of the condition or specific treatments you used.
Most journals allow 4-8 keywords but check the submission guidelines of your target journal to make sure.

Blur out the patient's face as well as any tattoos, birthmarks, or unrelated scars that are visible in diagnostic images.

Step 6 Include your acknowledgments and conflict of interest statement.

It's common to thank the patient, but that's up to you. Even if you don't, include a statement indicating that you have the patient's written, informed consent to publish the information.
Read the journal's submission guidelines for a definition of what that journal considers a conflict of interest. They're generally the same, but some might be stricter than others. [22] X Research source

Step 7 Compile and format your reference section.

If you're not familiar with the citation style used by your target journal, check online for a guide. There might also be one available at your hospital or medical school library.
Medical librarians can also help with citation style and references if you run into something tricky—don't just wing it! Correct citation style insures that readers can access the materials you cite.

Step 8 Get feedback on your final draft.

It's also a good idea to get a beta reader who isn't a medical professional. Their comments can help you figure out where you need to clarify your points.
Read a lot of case studies published in your target journals—it will help you internalize the tone and style that journal is looking for.

Submitting Your Report to Publishers

Step 1 Choose target journals that publish similar content.

Look into the background and reputation of journals before you decide to submit to them. Only seek publication from reputable journals in which articles go through a peer-review process.
Find out what publishing fees the journals charge. Keep in mind that open-access journals tend to charge higher publishing fees. [26] X Research source
Read each journal's submission and editorial guidelines carefully. They'll tell you exactly how to format your case study, how long each section should be, and what citation style to use. [27] X Research source
For electronic journals that only publish case reports, try BMJ Case Reports , Journal of Medical Case Reports , or Radiology Case Reports .

Step 2 Submit your manuscript according to the journal's requirements.

If your manuscript isn't suitable for the journal you submitted to, the journal might offer to forward it to an associated journal where it would be a better fit.
When your manuscript is provisionally accepted, the journal will send it to other doctors for evaluation under the peer-review process.
Most medical journals don't accept simultaneous submissions, meaning you'll have to submit to your first choice, wait for their decision, then move to the next journal on the list if they don't bite.

Step 3 Revise your manuscript based on peer review comments.

Along with your revised manuscript, include a letter with your response to each of the reviewer's comments. Where you made revisions, add page numbers to indicate where the revisions are that address that reviewer's comments.
Sometimes, doctors involved in the peer review process will indicate that the journal should reject the manuscript. If that's the case, you'll get a letter explaining why your case study report won't be published and you're free to submit it elsewhere.

Step 4 Complete final copy-editing if the editors approve your article.

Some journals require you to have your article professionally copy-edited at your own cost while others do this in-house. The editors will let you know what you're responsible for.

Step 5 Pay the article processing charge if your article is accepted.

With your acceptance letter, you'll get instructions on how to make payment and how much you owe. Take note of the deadline and make sure you pay it as soon as possible to avoid publication delays.
Some journals will publish for free, with an "open-access option" that allows you to pay a fee only if you want open access to your article. [32] X Research source

Through the publishing agreement, you assign your copyright in the article to the journal. This allows the journal to legally publish your work. That assignment can be exclusive or non-exclusive and may only last for a specific term. Read these details carefully!
If you published an open-access article, you don't assign the copyright to the publisher. The publishing agreement merely gives the journal the right to publish the "Version of Record." [34] X Research source

How do I find a suitable case for a report?

Step 1 Keep your eye out for unusual or interesting cases.

A rare disease, or unusual presentation of any disease
An unusual combination of diseases or conditions
A difficult or inconclusive diagnosis
Unexpected developments or responses to treatment
Personal impact
Observations that shed new light on the patient's disease or condition

Step 2 Discuss possible cases with your medical team.

There might be other members of your medical team that want to help with writing. If so, use one of these brainstorming sessions to divvy up writing responsibilities in a way that makes the most sense given your relative skills and experience.
Senior doctors might also be able to name some journals that would potentially publish your case study. [37] X Research source

Expert Q&A

↑ https://www.elsevier.com/connect/authors-update/the-dos-and-donts-of-writing-and-publishing-case-reports
↑ https://www.bmj.com/content/350/bmj.h2693
↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686928/
↑ https://health.usf.edu/medicine/internalmedicine/im-impact/~/media/B3A3421F4C144FA090AE965C21791A3C.ashx
↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476221/
↑ https://www.springer.com/gp/authors-editors/authorandreviewertutorials/writing-a-journal-manuscript/title-abstract-and-keywords/10285522
↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
↑ https://thelancet.com/pb/assets/raw/Lancet/authors/tl-info-for-authors.pdf
↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-017-1351-y
↑ https://guides.himmelfarb.gwu.edu/casereports
↑ https://casereports.bmj.com/pages/authors/
↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-7-239
↑ https://research.chm.msu.edu/students-residents/writing-a-case-report
↑ https://www.elsevier.com/__data/assets/pdf_file/0006/98619/Sample-P-copyright-2.pdf
↑ https://authorservices.taylorandfrancis.com/publishing-your-research/moving-through-production/copyright-for-journal-authors/#

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The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment.

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Medical Student Case Studies

Each student is required to prepare a teaching case to present to his/her colleagues and the course director. Past examples provided below.

General Diagnostic Case Studies

Arteriovenous Fistula Secondary to Trauma
Chylothorax, Cellulitis, Gas Gangrene
Ectopic ACTH-Secreting Tumor
Epiphrenic Diverticula
Incidental Mediastinal Hilar Lymphadenopathy
Liver Metastasis
Neurocystercircosis
Pneumoperitoneum
Pneumothorax
Posterior Urethralcutaneous Fistula
Renal Cysts
Rocky Mountain Spotted Fever
Septic Emboli to the Brain
Submassive Bilateral PE
Tailgut Duplication Cyst
Tension Pneumocephalus
Tracheo-Esophageal Fistula
Vestibular Schwannoma

Radiology Pathology Correlation Case Studies

Adenoid Cystic Carcinoma
Cholangiocarcinoma
Cryptococcal PNA
Disseminated Histoplasmosis
Lung Adenocarcinoma
Marginal Zone B-cell Lymphoma
Metastatic Urothelial Carcinoma
Mixed Clear Cell Papillary RCC
Ovarian Carcinoma
Pancreatic Adenocarcinoma
Squamous Cell Carcinoma of the Lung
Squamous Cell Carcinoma
Uterine Leiomyosarcoma
Cervical Adenosquamous Carcinoma
Clear Cell Renal Cell Carcinoma
Esophageal Adenocarcinoma
Metastic Esophageal Gastrointestinal Stomal Tumor
Ocular Melanoma with Mets to Liver
Pancreatic Metatasis
Papillary Thyroid Carcinoma
Papillary Thyroid Carcinoma #2
Renal Transplant Rejection
Small Cell Lung Cancer
Urothelial Carcinoma Lung Met
Yolk Sac Tumor
Burkitt’s Lymphoma
Ewing Sarcoma
Hepatocellular Carcinoma
Hepatocellular Carcinoma #2
High-grade Serous Ovarian Carcinoma
Metastatic Duodenal Adenocarcinoma
Metastatic Melanoma
Ovarian Cancer
Papillary Thyroid Carcinoma #3
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Writing a Case Report

This page is intended for medical students, residents or others who do not have much experience with case reports, but are planning on writing one.

What is a case report? A medical case report, also known as a case study, is a detailed description of a clinical encounter with a patient. The most important aspect of a case report, i.e. the reason you would go to the trouble of writing one, is that the case is sufficiently unique, rare or interesting such that other medical professionals will learn something from it.

Case reports are commonly of the following categories :

- Rare diseases

- Unusual presentation of disease

- Unexpected events

- Unusual combination of diseases or conditions

- Difficult or inconclusive diagnosis

- Treatment or management challenges

- Personal impact

- Observations that shed new light on a disease or condition

- Anatomical variations

It is important that you recognize what is unique or interesting about your case, and this must be described clearly in the case report.

Case reports generally take the format of :

1. Background

2. Case presentation

3. Observations and investigation

4. Diagnosis

5. Treatment

7. Discussion

Does a case report require IRB approval?

Case reports typically discuss a single patient. If this is true for your case report, then it most likely does not require IRB approval because it not considered research. If you have more than one patient, your study could qualify as a Case Series, which would require IRB review. If you have questions, you chould check your local IRB's guidelines on reviewing case reports.

Are there other rules for writing a case report?

First, you will be collecting protected health information, thus HIPAA applies to case reports. Spectrum Health has created a very helpful guidance document for case reports, which you can see here: Case Report Guidance - Spectrum Health

While this guidance document was created by Spectrum Health, the rules and regulations outlined could apply to any case report. This includes answering questions like: Do I need written HIPAA authorization to publish a case report? When do I need IRB review of a case report? What qualifies as a patient identifier?

How do I get started?

1. We STRONGLY encourage you to consult the CARE Guidelines, which provide guidance on writing case reports - https://www.care-statement.org/

Specifically, the checklist - https://www.care-statement.org/checklist - which explains exactly the information you should collect and include in your case report.

2. Identify a case. If you are a medical student, you may not yet have the clinical expertise to determine if a specific case is worth writing up. If so, you must seek the help of a clinician. It is common for students to ask attendings or residents if they have any interesting cases that can be used for a case report.

3. Select a journal or two to which you think you will submit the case report. Journals often have specific requirements for publishing case reports, which could include a requirement for informed consent, a letter or statement from the IRB and other things. Journals may also charge publication fees (see Is it free to publish? below)

4. Obtain informed consent from the patient (see " Do I have to obtain informed consent from the patient? " below). Journals may have their own informed consent form that they would like you to use, so please look for this when selecting a journal.

Once you've identified the case, selected an appropriate journal(s), and considered informed consent, you can collect the required information to write the case report.

How do I write a case report?

Once you identify a case and have learned what information to include in the case report, try to find a previously published case report. Finding published case reports in a similar field will provide examples to guide you through the process of writing a case report.

One journal you can consult is BMJ Case Reports . MSU has an institutional fellowship with BMJ Case Reports which allows MSU faculty, staff and students to publish in this journal for free. See this page for a link to the journal and more information on publishing- https://lib.msu.edu/medicalwriting_publishing/

There are numerous other journals where you can find published case reports to help guide you in your writing.

Do I have to obtain informed consent from the patient?

The CARE guidelines recommend obtaining informed consent from patients for all case reports. Our recommendation is to obtain informed consent from the patient. Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports before publishing. The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible). Please consider this as well.

If required, it is recommended you obtain informed consent before the case report is written.

An example of a case report consent form can be found on the BMJ Case Reports website, which you can access via the MSU library page - https://casereports.bmj.com/ . Go to "Instructions for Authors" and then "Patient Consent" to find the consent form they use. You can create a similar form to obtain consent from your patient. If you have identified a journal already, please consult their requirements and determine if they have a specific consent form they would like you to use.

Seek feedback

Once you have written a draft of the case report, you should seek feedback on your writing, from experts in the field if possible, or from those who have written case reports before.

Selecting a journal

Aside from BMJ Case Reports mentioned above, there are many, many journals out there who publish medical case reports. Ask your mentor if they have a journal they would like to use. If you need to select on your own, here are some strategies:

1. Do a PubMed search. https://pubmed.ncbi.nlm.nih.gov/

a. Do a search for a topic, disease or other feature of your case report

b. When the results appear, on the left side of the page is a limiter for "article type". Case reports are an article type to which you can limit your search results. If you don't see that option on the left, click "additional filters".

c. Review the case reports that come up and see what journals they are published in.

2. Use JANE - https://jane.biosemantics.org/

3. Check with specialty societies. Many specialty societies are affiliated with one or more journal, which can be reviewed for ones that match your needs

4. Search through individual publisher journal lists. Elsevier publishes many different medical research journals, and they have a journal finder, much like JANE ( https://journalfinder.elsevier.com/ ). This is exclusive to Elsevier journals. There are many other publishers of medical journals for review, including Springer, Dove Press, BMJ, BMC, Wiley, Sage, Nature and many others.

Is it free to publish ?

Be aware that it may not be free to publish your case report. Many journals charge publication fees. Of note, many open access journals charge author fees of thousands of dollars. Other journals have smaller page charges (i.e. $60 per page), and still others will publish for free, with an "open access option". It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish. MSU-CHM does NOT have funds to support publication costs, so this is an important step if you do not want to pay out of pocket for publishing

*A more thorough discussion on finding a journal, publication costs, predatory journals and other publication-related issues can be found here: https://research.chm.msu.edu/students-residents/finding-a-journal

Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. 2013. The CARE guidelines: Consensus-based clinical case reporting guideline development. Glob Adv Health Med . 2:38-43. doi: 10.7453/gahmj.2013.008

Riley DS, Barber MS, Kienle GS, AronsonJK, von Schoen-Angerer T, Tugwell P, Kiene H, Helfand M, Altman DG, Sox H, Werthmann PG, Moher D, Rison RA, Shamseer L, Koch CA, Sun GH, Hanaway P, Sudak NL, Kaszkin-Bettag M, Carpenter JE, Gagnier JJ. 2017. CARE guidelines for case reports: explanation and elaboration document . J Clin Epidemiol . 89:218-234. doi: 10.1016/j.jclinepi.2017.04.026

Guidelines to writing a clinical case report. 2017. Heart Views . 18:104-105. doi: 10.4103/1995-705X.217857

Ortega-Loubon C, Culquichicon C, Correa R. The importance of writing and publishing case reports during medical education. 2017. Cureus. 9:e1964. doi: 10.7759/cureus.1964

Writing and publishing a useful and interesting case report. 2019. BMJ Case Reports. https://casereports.bmj.com/pages/wp-content/uploads/sites/69/2019/04/How-to-write-a-Case-Report-DIGITAL.pdf

Camm CF. Writing an excellent case report: EHJ Case Reports , Case of the Year 2019. 2020. European Heart Jounrnal. 41:1230-1231. https://doi.org/10.1093/eurheartj/ehaa176

*content developed by Mark Trottier, PhD

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Writing a case report...

Writing a case report in 10 steps

Related content
Peer review
Victoria Stokes , foundation year 2 doctor, trauma and orthopaedics, Basildon Hospital ,
Caroline Fertleman , paediatrics consultant, The Whittington Hospital NHS Trust
victoria.stokes1{at}nhs.net

Victoria Stokes and Caroline Fertleman explain how to turn an interesting case or unusual presentation into an educational report

It is common practice in medicine that when we come across an interesting case with an unusual presentation or a surprise twist, we must tell the rest of the medical world. This is how we continue our lifelong learning and aid faster diagnosis and treatment for patients.

It usually falls to the junior to write up the case, so here are a few simple tips to get you started.

First steps

Begin by sitting down with your medical team to discuss the interesting aspects of the case and the learning points to highlight. Ideally, a registrar or middle grade will mentor you and give you guidance. Another junior doctor or medical student may also be keen to be involved. Allocate jobs to split the workload, set a deadline and work timeframe, and discuss the order in which the authors will be listed. All listed authors should contribute substantially, with the person doing most of the work put first and the guarantor (usually the most senior team member) at the end.

Getting consent

Gain permission and written consent to write up the case from the patient or parents, if your patient is a child, and keep a copy because you will need it later for submission to journals.

Information gathering

Gather all the information from the medical notes and the hospital’s electronic systems, including copies of blood results and imaging, as medical notes often disappear when the patient is discharged and are notoriously difficult to find again. Remember to anonymise the data according to your local hospital policy.

Write up the case emphasising the interesting points of the presentation, investigations leading to diagnosis, and management of the disease/pathology. Get input on the case from all members of the team, highlighting their involvement. Also include the prognosis of the patient, if known, as the reader will want to know the outcome.

Coming up with a title

Discuss a title with your supervisor and other members of the team, as this provides the focus for your article. The title should be concise and interesting but should also enable people to find it in medical literature search engines. Also think about how you will present your case study—for example, a poster presentation or scientific paper—and consider potential journals or conferences, as you may need to write in a particular style or format.

Background research

Research the disease/pathology that is the focus of your article and write a background paragraph or two, highlighting the relevance of your case report in relation to this. If you are struggling, seek the opinion of a specialist who may know of relevant articles or texts. Another good resource is your hospital library, where staff are often more than happy to help with literature searches.

How your case is different

Move on to explore how the case presented differently to the admitting team. Alternatively, if your report is focused on management, explore the difficulties the team came across and alternative options for treatment.

Finish by explaining why your case report adds to the medical literature and highlight any learning points.

Writing an abstract

The abstract should be no longer than 100-200 words and should highlight all your key points concisely. This can be harder than writing the full article and needs special care as it will be used to judge whether your case is accepted for presentation or publication.

Discuss with your supervisor or team about options for presenting or publishing your case report. At the very least, you should present your article locally within a departmental or team meeting or at a hospital grand round. Well done!

Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare that we have no competing interests.

Health Case Studies

(29 reviews)

Glynda Rees, British Columbia Institute of Technology

Rob Kruger, British Columbia Institute of Technology

Janet Morrison, British Columbia Institute of Technology

Publisher: BCcampus

Language: English

Formats Available

Conditions of use.

Learn more about reviews.

Reviewed by Jessica Sellars, Medical assistant office instructor, Blue Mountain Community College on 10/11/23

Comprehensiveness rating: 5 see less

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and plan. There is an appendix to refer to as well if you are needing to find something specific quickly. I have been looking for something like this to help my students have a base to do their project on. This is the most comprehensive version I have found on the subject.

Content Accuracy rating: 5

This is a book compiled of medical case studies. It is very accurate and can be used to learn from great care and mistakes.

Relevance/Longevity rating: 5

This material is very relevant in this context. It also has plenty of individual case studies to utilize in many ways in all sorts of medical courses. This is a very useful textbook and it will continue to be useful for a very long time as you can still learn from each study even if medicine changes through out the years.

Clarity rating: 5

The author put a lot of thought into the ease of accessibility and reading level of the target audience. There is even a "how to use this resource" section which could be extremely useful to students.

Consistency rating: 5

The text follows a very consistent format throughout the book.

Modularity rating: 5

Each case study is individual broken up and in a group of similar case studies. This makes it extremely easy to utilize.

Organization/Structure/Flow rating: 5

The book is very organized and the appendix is through. It flows seamlessly through each case study.

Interface rating: 5

I had no issues navigating this book, It was clearly labeled and very easy to move around in.

Grammatical Errors rating: 5

I did not catch any grammar errors as I was going through the book

Cultural Relevance rating: 5

This is a challenging question for any medical textbook. It is very culturally relevant to those in medical or medical office degrees.

I have been looking for something like this for years. I am so happy to have finally found it.

Reviewed by Cindy Sun, Assistant Professor, Marshall University on 1/7/23

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and students. For faculty, the introduction section titled ‘How to use this resource’ and individual notes to educators before each case study contain application tips. An appendix overview lists key elements as issues / concepts, scenario context, and healthcare roles for each case study. For students, learning objectives are presented at the beginning of each case study to provide a framework of expectations.

The content is presented accurately and realistic.

The case studies read similar to ‘A Day In the Life of…’ with detailed intraprofessional communications similar to what would be overheard in patient care areas. The authors present not only the view of the patient care nurse, but also weave interprofessional vantage points through each case study by including patient interaction with individual professionals such as radiology, physician, etc.

In addition to objective assessment findings, the authors integrate standard orders for each diagnosis including medications, treatments, and tests allowing the student to incorporate pathophysiology components to their assessments.

Each case study is arranged in the same framework for consistency and ease of use.

This compilation of eight healthcare case studies focusing on new onset and exacerbation of prevalent diagnoses, such as heart failure, deep vein thrombosis, cancer, and chronic obstructive pulmonary disease advancing to pneumonia.

Each case study has a photo of the ‘patient’. Simple as this may seem, it gives an immediate mental image for the student to focus.

Interface rating: 4

As noted by previous reviewers, most of the links do not connect active web pages. This may be due to the multiple options for accessing this resource (pdf download, pdf electronic, web view, etc.).

Grammatical Errors rating: 4

A minor weakness that faculty will probably need to address prior to use is regarding specific term usages differences between Commonwealth countries and United States, such as lung sound descriptors as ‘quiet’ in place of ‘diminished’ and ‘puffers’ in place of ‘inhalers’.

The authors have provided a multicultural, multigenerational approach in selection of patient characteristics representing a snapshot of today’s patient population. Additionally, one case study focusing on heart failure is about a middle-aged adult, contrasting to the average aged patient the students would normally see during clinical rotations. This option provides opportunities for students to expand their knowledge on risk factors extending beyond age.

This resource is applicable to nursing students learning to care for patients with the specific disease processes presented in each case study or for the leadership students focusing on intraprofessional communication. Educators can assign as a supplement to clinical experiences or as an in-class application of knowledge.

Reviewed by Stephanie Sideras, Assistant Professor, University of Portland on 8/15/22

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five overarching learning objectives pulled from the Institute of Medicine core competencies will clearly resonate with any faculty familiar with Quality and Safety Education for Nurses curriculum.

The presentation of symptoms, treatments and management of the health alterations was accurate. Dialogue between the the interprofessional team was realistic. At times the formatting of lab results was confusing as they reflected reference ranges specific to the Canadian healthcare system but these occurrences were minimal and could be easily adapted.

The focus for learning from these case studies was communication - patient centered communication and interprofessional team communication. Specific details, such as drug dosing, was minimized, which increases longevity and allows for easy individualization of the case data.

While some vocabulary was specific to the Canadian healthcare system, overall the narrative was extremely engaging and easy to follow. Subjective case data from patient or provider were formatted in italics and identified as 'thoughts'. Objective and behavioral case data were smoothly integrated into the narrative.

The consistency of formatting across the eight cases was remarkable. Specific learning objectives are identified for each case and these remain consistent across the range of cases, varying only in the focus for the goals for each different health alterations. Each case begins with presentation of essential patient background and the progress across the trajectory of illness as the patient moves from location to location encountering different healthcare professionals. Many of the characters (the triage nurse in the Emergency Department, the phlebotomist) are consistent across the case situations. These consistencies facilitate both application of a variety of teaching methods and student engagement with the situated learning approach.

Case data is presented by location and begins with the patient's first encounter with the healthcare system. This allows for an examination of how specific trajectories of illness are manifested and how care management needs to be prioritized at different stages. This approach supports discussions of care transitions and the complexity of the associated interprofessional communication.

The text is well organized. The case that has two levels of complexity is clearly identified

The internal links between the table of contents and case specific locations work consistently. In the EPUB and the Digital PDF the external hyperlinks are inconsistently valid.

The grammatical errors were minimal and did not detract from readability

Cultural diversity is present across the cases in factors including race, ethnicity, socioeconomic status, family dynamics and sexual orientation.

The level of detail included in these cases supports a teaching approach to address all three spectrums of learning - knowledge, skills and attitudes - necessary for the development of competent practice. I also appreciate the inclusion of specific assessment instruments that would facilitate a discussion of evidence based practice. I will enjoy using these case to promote clinical reasoning discussions of data that is noticed and interpreted with the resulting prioritizes that are set followed by reflections that result from learner choices.

Reviewed by Chris Roman, Associate Professor, Butler University on 5/19/22

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various... read more

Comprehensiveness rating: 4 see less

The narrative form of the cases is less subject to issues of accuracy than a more content-based book would be. That said, the cases are realistic and reasonable, avoiding being too mundane or too extreme.

These cases are narrative and do not include many specific mentions of drugs, dosages, or other aspects of clinical care that may grow/evolve as guidelines change. For this reason, the cases should be “evergreen” and can be modified to suit different types of learners.

Clarity rating: 4

The text is written in very accessible language and avoids heavy use of technical language. Depending on the level of learner, this might even be too simplistic and omit some details that would be needed for physicians, pharmacists, and others to make nuanced care decisions.

The format is very consistent with clear labeling at transition points.

The authors point out in the introductory materials that this text is designed to be used in a modular fashion. Further, they have built in opportunities to customize each cases, such as giving dates of birth at “19xx” to allow for adjustments based on instructional objectives, etc.

The organization is very easy to follow.

I did not identify any issues in navigating the text.

The text contains no grammatical errors, though the language is a little stiff/unrealistic in some cases.

Cases involve patients and members of the care team that are of varying ages, genders, and racial/ethnic backgrounds

Reviewed by Trina Larery, Assistant Professor, Pittsburg State University on 4/5/22

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand... read more

Content Accuracy rating: 4

The treatments were explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse. The case studies were accurate in explanation. The DVT case study incorrectly identifies the location of the clot in the popliteal artery instead of in the vein.

The content is relevant to a variety of different types of health care providers and due to the general nature of the cases, will remain relevant over time. Updates should be made annually to the hyperlinks and to assure current standard of practice is still being met.

Clear, simple and easy to read.

Consistent with healthcare terminology and framework throughout all eight case studies.

The text is modular. Cases can be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point providing great flexibility. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

The book is well organized, presenting in a logical clear fashion. The appendix allows the student to move about the case study without difficulty.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change based on current guidelines. A few hyperlinks had "page not found".

Few grammatical errors were noted in text.

The case studies include people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. There are roughly 25 broken online links or "pages not found", care needs to be taken to update at least annually and assure links are valid and utilizing the most up to date information.

Reviewed by Benjamin Silverberg, Associate Professor/Clinician, West Virginia University on 3/24/22

Comprehensiveness rating: 3 see less

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what is going on where, especially since each case is largely conversation-based. Since this presents 8 cases (really 7 with one being expanded upon), there are many medical topics (and venues) that are not included. It's impossible to include every kind of situation, but I'd love to see inclusion of sexual health, renal pathology, substance abuse, etc.

Though there are differences in how care can be delivered based on personal style, changing guidelines, available supplies, etc, the medical accuracy seems to be high. I did not detect bias or industry influence.

Relevance/Longevity rating: 4

Medications are generally listed as generics, with at least current dosing recommendations. The text gives a picture of what care looks like currently, but will be a little challenging to update based on new guidelines (ie, it can be hard to find the exact page in which a medication is dosed/prescribed). Even if the text were to be a little out of date, an instructor can use that to point out what has changed (and why).

Clear text, usually with definitions of medical slang or higher-tier vocabulary. Minimal jargon and there are instances where the "characters" are sorting out the meaning as well, making it accessible for new learners, too.

Overall, the style is consistent between cases - largely broken up into scenes and driven by conversation rather than descriptions of what is happening.

There are 8 (well, again, 7) cases which can be reviewed in any order. Case #2 builds upon #1, which is intentional and a good idea, though personally I would have preferred one case to have different possible outcomes or even a recurrence of illness. Each scene within a case is reasonably short.

Organization/Structure/Flow rating: 4

These cases are modular and don't really build on concepts throughout. As previously stated, case #2 builds upon #1, but beyond that, there is no progression. (To be sure, the authors suggest using case #1 for newer learners and #2 for more advanced ones.) The text would benefit from thematic grouping, a longer introduction and debriefing for each case (there are learning objectives but no real context in medical education nor questions to reflect on what was just read), and progressively-increasing difficulty in medical complexity, ethics, etc.

I used the PDF version and had no interface issues. There are minimal photographs and charts. Some words are marked in blue but those did not seem to be hyperlinked anywhere.

No noticeable errors in grammar, spelling, or formatting were noted.

I appreciate that some diversity of age and ethnicity were offered, but this could be improved. There were Canadian Indian and First Nations patients, for example, as well as other characters with implied diversity, but there didn't seem to be any mention of gender diverse or non-heterosexual people, or disabilities. The cases tried to paint family scenes (the first patient's dog was fairly prominently mentioned) to humanize them. Including more cases would allow for more opportunities to include sex/gender minorities, (hidden) disabilities, etc.

The text (originally from 2017) could use an update. It could be used in conjunction with other Open Texts, as a compliment to other coursework, or purely by itself. The focus is meant to be on improving communication, but there are only 3 short pages at the beginning of the text considering those issues (which are really just learning objectives). In addition to adding more cases and further diversity, I personally would love to see more discussion before and after the case to guide readers (and/or instructors). I also wonder if some of the ambiguity could be improved by suggesting possible health outcomes - this kind of counterfactual comparison isn't possible in real life and could be really interesting in a text. Addition of comprehension/discussion questions would also be worthwhile.

Reviewed by Danielle Peterson, Assistant Professor, University of Saint Francis on 12/31/21

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare workers in acute hospital settings. The cases are primarily set in the inpatient hospital setting, so the bulk of the clinical information is basic emergency care and inpatient protocol: vitals, breathing, medication management, etc. The text provides a table of contents at opening of the text and a handy appendix at the conclusion of the text that outlines each case’s issue(s), scenario, and healthcare roles. No index or glossary present.

Although easy to update, it should be noted that the cases are taking place in a Canadian healthcare system. Terms may be unfamiliar to some students including “province,” “operating theatre,” “physio/physiotherapy,” and “porter.” Units of measurement used include Celsius and meters. Also, the issue of managed care, health insurance coverage, and length of stay is missing for American students. These are primary issues that dictate much of the healthcare system in the US and a primary job function of social workers, nurse case managers, and medical professionals in general. However, instructors that wish to add this to the case studies could do so easily.

The focus of this text is on healthcare communication which makes it less likely to become obsolete. Much of the clinical information is stable healthcare practice that has been standard of care for quite some time. Nevertheless, given the nature of text, updates would be easy to make. Hyperlinks should be updated to the most relevant and trustworthy sources and checked frequently for effectiveness.

The spacing that was used to note change of speaker made for ease of reading. Although unembellished and plain, I expect students to find this format easy to digest and interesting, especially since the script is appropriately balanced with ‘human’ qualities like the current TV shows and songs, the use of humor, and nonverbal cues.

A welcome characteristic of this text is its consistency. Each case is presented in a similar fashion and the roles of the healthcare team are ‘played’ by the same character in each of the scenarios. This allows students to see how healthcare providers prioritize cases and juggle the needs of multiple patients at once. Across scenarios, there was inconsistency in when clinical terms were hyperlinked.

The text is easily divisible into smaller reading sections. However, since the nature of the text is script-narrative format, if significant reorganization occurs, one will need to make sure that the communication of the script still makes sense.

The text is straightforward and presented in a consistent fashion: learning objectives, case history, a script of what happened before the patient enters the healthcare setting, and a script of what happens once the patient arrives at the healthcare setting. The authors use the term, “ideal interactions,” and I would agree that these cases are in large part, ‘best case scenarios.’ Due to this, the case studies are well organized, clear, logical, and predictable. However, depending on the level of student, instructors may want to introduce complications that are typical in the hospital setting.

The interface is pleasing and straightforward. With exception to the case summary and learning objectives, the cases are in narrative, script format. Each case study supplies a photo of the ‘patient’ and one of the case studies includes a link to a 3-minute video that introduces the reader to the patient/case. One of the highlights of this text is the use of hyperlinks to various clinical practices (ABG, vital signs, transfer of patient). Unfortunately, a majority of the links are broken. However, since this is an open text, instructors can update the links to their preference.

Although not free from grammatical errors, those that were noticed were minimal and did not detract from reading.

Cultural Relevance rating: 4

Cultural diversity is visible throughout the patients used in the case studies and includes factors such as age, race, socioeconomic status, family dynamics, and sexual orientation. A moderate level of diversity is noted in the healthcare team with some stereotypes: social workers being female, doctors primarily male.

As a social work instructor, I was grateful to find a text that incorporates this important healthcare role. I would have liked to have seen more content related to advance directives, mediating decision making between the patient and care team, emotional and practical support related to initial diagnosis and discharge planning, and provision of support to colleagues, all typical roles of a medical social worker. I also found it interesting that even though social work was included in multiple scenarios, the role was only introduced on the learning objectives page for the oncology case.

Reviewed by Crystal Wynn, Associate Professor, Virginia State University on 7/21/21

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied health care team members are represented within the case study. Key terms appear throughout the case study textbook and readers are able to click on a hyperlink which directs them to the definition and an explanation of the key term.

Content is accurate, error-free and unbiased.

The content is up-to-date, but not in a way that will quickly make the text obsolete within a short period of time. The text is written and/or arranged in such a way that necessary updates will be relatively easy and straightforward to implement.

The text is written in lucid, accessible prose, and provides adequate context for any jargon/technical terminology used

The text is internally consistent in terms of terminology and framework.

The text is easily and readily divisible into smaller reading sections that can be assigned at different points within the course. Each case can be divided into a chronic disease state unit, which will allow the reader to focus on one section at a time.

Organization/Structure/Flow rating: 3

The topics in the text are presented in a logical manner. Each case provides an excessive amount of language that provides a description of the case. The cases in this text reads more like a novel versus a clinical textbook. The learning objectives listed within each case should be in the form of questions or activities that could be provided as resources for instructors and teachers.

Interface rating: 3

There are several hyperlinks embedded within the textbook that are not functional.

The text contains no grammatical errors.

Cultural Relevance rating: 3

The text is not culturally insensitive or offensive in any way. More examples of cultural inclusiveness is needed throughout the textbook. The cases should be indicative of individuals from a variety of races and ethnicities.

Reviewed by Rebecca Hillary, Biology Instructor, Portland Community College on 6/15/21

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health care program. I read the textbook in E-reader format and this includes hyperlinks that bring the students to subsequent clinical study if the book is being used in a clinical classroom. This book is significantly more comprehensive in its approach from other case studies I have read because it provides a bird’s eye view of the many clinicians, technicians, and hospital staff working with one patient. The book also provides real time measurements for patients that change as they travel throughout the hospital until time of discharge.

Each case gave an accurate sense of the chaos that would be present in an emergency situation and show how the conditions affect the practitioners as well as the patients. The reader gets an accurate big picture--a feel for each practitioner’s point of view as well as the point of view of the patient and the patient’s family as the clock ticks down and the patients are subjected to a number of procedures. The clinical information contained in this textbook is all in hyperlinks containing references to clinical skills open text sources or medical websites. I did find one broken link on an external medical resource.

The diseases presented are relevant and will remain so. Some of the links are directly related to the Canadian Medical system so they may not be applicable to those living in other regions. Clinical links may change over time but the text itself will remain relevant.

Each case study clearly presents clinical data as is it recorded in real time.

Each case study provides the point of view of several practitioners and the patient over several days. While each of the case studies covers different pathology they all follow this same format, several points of view and data points, over a number of days.

The case studies are divided by days and this was easy to navigate as a reader. It would be easy to assign one case study per body system in an Anatomy and Physiology course, or to divide them up into small segments for small in class teaching moments.

The topics are presented in an organized way showing clinical data over time and each case presents a large number of view points. For example, in the first case study, the patient is experiencing difficulty breathing. We follow her through several days from her entrance to the emergency room. We meet her X Ray Technicians, Doctor, Nurses, Medical Assistant, Porter, Physiotherapist, Respiratory therapist, and the Lab Technicians running her tests during her stay. Each practitioner paints the overall clinical picture to the reader.

I found the text easy to navigate. There were not any figures included in the text, only clinical data organized in charts. The figures were all accessible via hyperlink. Some figures within the textbook illustrating patient scans could have been helpful but I did not have trouble navigating the links to visualize the scans.

I did not see any grammatical errors in the text.

The patients in the text are a variety of ages and have a variety of family arrangements but there is not much diversity among the patients. Our seven patients in the eight case studies are mostly white and all cis gendered.

Some of the case studies, for example the heart failure study, show clinical data before and after drug treatments so the students can get a feel for mechanism in physiological action. I also liked that the case studies included diet and lifestyle advice for the patients rather than solely emphasizing these pharmacological interventions. Overall, I enjoyed reading through these case studies and I plan to utilize them in my Anatomy and Physiology courses.

Reviewed by Richard Tarpey, Assistant Professor, Middle Tennessee State University on 5/11/21

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate for entry-level health care students. The book includes important health problems, but I would like to see coverage of at least one more chronic/lifestyle issue such as diabetes. The book covers adult issues only.

Content is accurate without bias

The content of the book is relevant and up-to-date. It addresses conditions that are prevalent in today's population among adults. There are no pediatric cases, but this does not significantly detract from the usefulness of the text. The format of the book lends to easy updating of data or information.

The book is written with clarity and is easy to read. The writing style is accessible and technical terminology is explained with links to more information.

Consistency is present. Lack of consistency is typically a problem with case study texts, but this book is consistent with presentation, format, and terminology throughout each of the eight cases.

The book has high modularity. Each of the case studies can be used independently from the others providing flexibility. Additionally, each case study can be partitioned for specific learning objectives based on the learning objectives of the course or module.

The book is well organized, presenting students conceptually with differing patient flow patterns through a hospital. The patient information provided at the beginning of each case is a wonderful mechanism for providing personal context for the students as they consider the issues. Many case studies focus on the problem and the organization without students getting a patient's perspective. The patient perspective is well represented in these cases.

The navigation through the cases is good. There are some terminology and procedure hyperlinks within the cases that do not work when accessed. This is troubling if you intend to use the text for entry-level health care students since many of these links are critical for a full understanding of the case.

There are some non-US variants of spelling and a few grammatical errors, but these do not detract from the content of the messages of each case.

The book is inclusive of differing backgrounds and perspectives. No insensitive or offensive references were found.

I like this text for its application flexibility. The book is useful for non-clinical healthcare management students to introduce various healthcare-related concepts and terminology. The content is also helpful for the identification of healthcare administration managerial issues for students to consider. The book has many applications.

Reviewed by Paula Baldwin, Associate Professor/Communication Studies, Western Oregon University on 5/10/21

The different case studies fall on a range, from crisis care to chronic illness care. read more

The different case studies fall on a range, from crisis care to chronic illness care.

The contents seems to be written as they occurred to represent the most complete picture of each medical event's occurence.

These case studies are from the Canadian medical system, but that does not interfere with it's applicability.

It is written for a medical audience, so the terminology is mostly formal and technical.

Some cases are shorter than others and some go in more depth, but it is not problematic.

The eight separate case studies is the perfect size for a class in the quarter system. You could combine this with other texts, videos or learning modalities, or use it alone.

As this is a case studies book, there is not a need for a logical progression in presentation of topics.

No problems in terms of interface.

I have not seen any grammatical errors.

I did not see anything that was culturally insensitive.

I used this in a Health Communication class and it has been extraordinarily successful. My studies are analyzing the messaging for the good, the bad, and the questionable. The case studies are widely varied and it gives the class insights into hospital experiences, both front and back stage, that they would not normally be able to examine. I believe that because it is based real-life medical incidents, my students are finding the material highly engaging.

Reviewed by Marlena Isaac, Instructor, Aiken Technical College on 4/23/21

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with... read more

The case studies provided accurate information that relates to the named disease.

It is relevant to health care studies and the development of critical thinking.

Cases are straightforward with great clinical information.

Clinical information is provided concisely.

Appropriate for clinical case study.

Presented to facilitate information gathering.

Takes a while to navigate in the browser.

Cultural Relevance rating: 1

Text lacks adequate representation of minorities.

Reviewed by Kim Garcia, Lecturer III, University of Texas Rio Grande Valley on 11/16/20

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at different levels of clinical knowledge. The human element of both patient and health care provider is well captured. The cases are presented with a focus on interprofessional interaction and collaboration, more so than teaching medical content.

Content is accurate and un-biased. No errors noted. Most diagnostic and treatment information is general so it will remain relevant over time. The content of these cases is more appropriate for teaching interprofessional collaboration and less so for teaching the medical care for each diagnosis.

The content is relevant to a variety of different types of health care providers (nurses, radiologic technicians, medical laboratory personnel, etc) and due to the general nature of the cases, will remain relevant over time.

Easy to read. Clear headings are provided for sections of each case study and these section headings clearly tell when time has passed or setting has changed. Enough description is provided to help set the scene for each part of the case. Much of the text is written in the form of dialogue involving patient, family and health care providers, making it easy to adapt for role play. Medical jargon is limited and links for medical terms are provided to other resources that expound on medical terms used.

The text is consistent in structure of each case. Learning objectives are provided. Cases generally start with the patient at home and move with the patient through admission, testing and treatment, using a variety of healthcare services and encountering a variety of personnel.

The text is modular. Cases could be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

Each case follows a patient in a logical, chronologic fashion. A clear table of contents and appendix are provided which allows the user to quickly locate desired content. It would be helpful if the items in the table of contents and appendix were linked to the corresponding section of the text.

The hyperlinks to content outside this book work, however using the back arrow on your browser returns you to the front page of the book instead of to the point at which you left the text. I would prefer it if the hyperlinks opened in a new window or tab so closing that window or tab would leave you back where you left the text.

No grammatical errors were noted.

The text is culturally inclusive and appropriate. Characters, both patients and care givers are of a variety of races, ethnicities, ages and backgrounds.

I enjoyed reading the cases and reviewing this text. I can think of several ways in which I will use this content.

Reviewed by Raihan Khan, Instructor/Assistant Professor, James Madison University on 11/3/20

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients. read more

The health information contained in the textbook is mostly accurate.

I think the book is written focusing on the current culture and health issues faced by the patients. To keep the book relevant in the future, the contexts especially the culture/lifestyle/health care modalities, etc. would need to be updated regularly.

The language is pretty simple, clear, and easy to read.

There is no complaint about consistency. One of the main issues of writing a book, consistency was well managed by the authors.

The book is easy to explore based on how easy the setup is. Students can browse to the specific section that they want to read without much hassle of finding the correct information.

The organization is simple but effective. The authors organized the book based on what can happen in a patient's life and what possible scenarios students should learn about the disease. From that perspective, the book does a good job.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change that is beyond the author's control. It's frustrating for the reader when the external link shows no information.

The book is free of any major language and grammatical errors.

The book might do a little better in cultural competency. e.g. Last name Singh is mainly for Sikh people. In the text Harj and Priya Singh are Muslim. the authors can consult colleagues who are more familiar with those cultures and revise some cultural aspects of the cases mentioned in the book.

The book is a nice addition to the open textbook world. Hope to see more health issues covered by the book.

Reviewed by Ryan Sheryl, Assistant Professor, California State University, Dominguez Hills on 7/16/20

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality improvement, and informatics. While the case studies do not cover all medical conditions or bodily systems, the book is thorough in conveying details of various patients and medical team members in a hospital environment. Rather than an index or glossary at the end of the text, it contains links to outside websites for more information on medical tests and terms referenced in the cases.

The content provided is reflective of best practices in patient care, interdisciplinary collaboration, and communication at the time of publication. It is specifically accurate for the context of hospitals in Canada. The links provided throughout the text have the potential to supplement with up-to-date descriptions and definitions, however, many of them are broken (see notes in Interface section).

The content of the case studies reflects the increasingly complex landscape of healthcare, including a variety of conditions, ages, and personal situations of the clients and care providers. The text will require frequent updating due to the rapidly changing landscape of society and best practices in client care. For example, a future version may include inclusive practices with transgender clients, or address ways medical racism implicitly impacts client care (see notes in Cultural Relevance section).

The text is written clearly and presents thorough, realistic details about working and being treated in an acute hospital context.

The text is very straightforward. It is consistent in its structure and flow. It uses consistent terminology and follows a structured framework throughout.

Being a series of 8 separate case studies, this text is easily and readily divisible into smaller sections. The text was designed to be taken apart and used piece by piece in order to serve various learning contexts. The parts of each case study can also be used independently of each other to facilitate problem solving.

The topics in the case studies are presented clearly. The structure of each of the case studies proceeds in a similar fashion. All of the cases are set within the same hospital so the hospital personnel and service providers reappear across the cases, giving a textured portrayal of the experiences of the various service providers. The cases can be used individually, or one service provider can be studied across the various studies.

The text is very straightforward, without complex charts or images that could become distorted. Many of the embedded links are broken and require updating. The links that do work are a very useful way to define and expand upon medical terms used in the case studies.

Grammatical errors are minimal and do not distract from the flow of the text. In one instance the last name Singh is spelled Sing, and one patient named Fred in the text is referred to as Frank in the appendix.

The cases all show examples of health care personnel providing compassionate, client-centered care, and there is no overt discrimination portrayed. Two of the clients are in same-sex marriages and these are shown positively. It is notable, however, that the two cases presenting people of color contain more negative characteristics than the other six cases portraying Caucasian people. The people of color are the only two examples of clients who smoke regularly. In addition, the Indian client drinks and is overweight, while the First Nations client is the only one in the text to have a terminal diagnosis. The Indian client is identified as being Punjabi and attending a mosque, although there are only 2% Muslims in the Punjab province of India. Also, the last name Singh generally indicates a person who is a Hindu or Sikh, not Muslim.

Reviewed by Monica LeJeune, RN Instructor, LSUE on 4/24/20

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process. read more

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process.

Accurately presents health scenarios with real life assessment techniques and patient outcomes.

Relevant to nursing practice.

Clearly written and easily understood.

Consistent with healthcare terminology and framework

Has a good reading flow.

Topics presented in logical fashion

Easy to read.

No grammatical errors noted.

Text is not culturally insensitive or offensive.

Good book to have to teach nursing students.

Reviewed by april jarrell, associate professor, J. Sargeant Reynolds Community College on 1/7/20

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process. read more

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process.

The content is accurate and evidence based. There is no bias noted

The content in the text is relevant, up to date for nursing students. It will be easy to update content as needed because the framework allows for addition to the content.

The text is clear and easy to understand.

Framework and terminology is consistent throughout the text; the case study is a continual and takes the student on a journey with the patient. Great for learning!

The case studies can be easily divided into smaller sections to allow for discussions, and weekly studies.

The text and content progress in a logical, clear fashion allowing for progression of learning.

No interface issues noted with this text.

No grammatical errors noted in the text.

No racial or culture insensitivity were noted in the text.

I would recommend this text be used in nursing schools. The use of case studies are helpful for students to learn and practice the nursing process.

Reviewed by Lisa Underwood, Practical Nursing Instructor, NTCC on 12/3/19

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own set of learning objectives that can be tweaked to fit several allied health courses. Although the case studies are designed around the Canadian Healthcare System, they are quite easily adaptable to fit most any modern, developed healthcare system.

Content Accuracy rating: 3

Overall, the text is quite accurate. There is one significant error that needs to be addressed. It is located in the DVT case study. In the study, a popliteal artery clot is mislabeled as a DVT. DVTs are located in veins, not in arteries. That said, the case study on the whole is quite good. This case study could be used as a learning tool in the classroom for discussion purposes or as a way to test student understanding of DVTs, on example might be, "Can they spot the error?"

At this time, all of the case studies within the text are current. Healthcare is an ever evolving field that rests on the best evidence based practice. Keeping that in mind, educators can easily adapt the studies as the newest evidence emerges and changes practice in healthcare.

All of the case studies are well written and easy to understand. The text includes several hyperlinks and it also highlights certain medical terminology to prompt readers as a way to enhance their learning experience.

Across the text, the language, style, and format of the case studies are completely consistent.

The text is divided into eight separate case studies. Each case study may be used independently of the others. All case studies are further broken down as the focus patient passes through each aspect of their healthcare system. The text's modularity makes it possible to use a case study as individual work, group projects, class discussions, homework or in a simulation lab.

The case studies and the diagnoses that they cover are presented in such a way that educators and allied health students can easily follow and comprehend.

The book in itself is free of any image distortion and it prints nicely. The text is offered in a variety of digital formats. As noted in the above reviews, some of the hyperlinks have navigational issues. When the reader attempts to access them, a "page not found" message is received.

There were minimal grammatical errors. Some of which may be traced back to the differences in our spelling.

The text is culturally relevant in that it includes patients from many different backgrounds and ethnicities. This allows educators and students to explore cultural relevance and sensitivity needs across all areas in healthcare. I do not believe that the text was in any way insensitive or offensive to the reader.

By using the case studies, it may be possible to have an open dialogue about the differences noted in healthcare systems. Students will have the ability to compare and contrast the Canadian healthcare system with their own. I also firmly believe that by using these case studies, students can improve their critical thinking skills. These case studies help them to "put it all together".

Reviewed by Melanie McGrath, Associate Professor, TRAILS on 11/29/19

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case. read more

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case.

I saw no areas of inaccuracy

As in all healthcare texts, treatments and/or tests will change frequently. However, everything is currently up-to-date thus it should be a good reference for several years.

Each case is written so that any level of healthcare student would understand. Hyperlinks in the text is also very helpful.

All of the cases are written in a similar fashion.

Although not structured as a typical text, each case is easily assigned as a stand-alone.

Each case is organized clearly in an appropriate manner.

I did not see any issues.

I did not see any grammatical errors

The text seemed appropriately inclusive. There are no pediatric cases and no cases of intellectually-impaired patients, but those types of cases introduce more advanced problem-solving which perhaps exceed the scope of the text. May be a good addition to the text.

I found this text to be an excellent resource for healthcare students in a variety of fields. It would be best utilized in inter professional courses to help guide discussion.

Reviewed by Lynne Umbarger, Clinical Assistant Professor, Occupational Therapy, Emory and Henry College on 11/26/19

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational purposes. The material was easily understood by the students but challenging enough for classroom discussion. There are no mentions in the book about occupational therapy, but it is easy enough to add a couple words and make inclusion simple.

Very nice lab values are provided in the case study, making it more realistic for students.

These case studies focus on commonly encountered diagnoses for allied health and nursing students. They are comprehensive, realistic, and easily understood. The only difference is that the hospital in one case allows the patient's dog to visit in the room (highly unusual in US hospitals).

The material is easily understood by allied health students. The cases have links to additional learning materials for concepts that may be less familiar or should be explored further in a particular health field.

The language used in the book is consistent between cases. The framework is the same with each case which makes it easier to locate areas that would be of interest to a particular allied health profession.

The case studies are comprehensive but well-organized. They are short enough to be useful for class discussion or a full-blown assignment. The students seem to understand the material and have not expressed that any concepts or details were missing.

Each case is set up like the other cases. There are learning objectives at the beginning of each case to facilitate using the case, and it is easy enough to pull out material to develop useful activities and assignments.

There is a quick chart in the Appendix to allow the reader to determine the professions involved in each case as well as the pertinent settings and diagnoses for each case study. The contents are easy to access even while reading the book.

As a person who attends carefully to grammar, I found no errors in all of the material I read in this book.

There are a greater number of people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book. With each case, I could easily picture the person in the case. This book appears to be Canadian and more inclusive than most American books.

I was able to use this book the first time I accessed it to develop a classroom activity for first-year occupational therapy students and a more comprehensive activity for second-year students. I really appreciate the links to a multitude of terminology and medical lab values/issues for each case. I will keep using this book.

Reviewed by Cindy Krentz, Assistant Professor, Metropolitan State University of Denver on 6/15/19

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some understanding of the patient's background. I think it could benefit from having a glossary. I liked how the authors included the vital signs in an easily readable bar. I would have liked to see the labs also highlighted like this. I also felt that it would have been good written in a 'what would you do next?' type of case study.

The book is very accurate in language, what tests would be prudent to run and in the day in the life of the hospital in all cases. One inaccuracy is that the authors called a popliteal artery clot a DVT. The rest of the DVT case study was great, though, but the one mistake should be changed.

The book is up to date for now, but as tests become obsolete and new equipment is routinely used, the book ( like any other health textbook) will need to be updated. It would be easy to change, however. All that would have to happen is that the authors go in and change out the test to whatever newer, evidence-based test is being utilized.

The text is written clearly and easy to understand from a student's perspective. There is not too much technical jargon, and it is pretty universal when used- for example DVT for Deep Vein Thrombosis.

The book is consistent in language and how it is broken down into case studies. The same format is used for highlighting vital signs throughout the different case studies. It's great that the reader does not have to read the book in a linear fashion. Each case study can be read without needing to read the others.

The text is broken down into eight case studies, and within the case studies is broken down into days. It is consistent and shows how the patient can pass through the different hospital departments (from the ER to the unit, to surgery, to home) in a realistic manner. The instructor could use one or more of the case studies as (s)he sees fit.

The topics are eight different case studies- and are presented very clearly and organized well. Each one is broken down into how the patient goes through the system. The text is easy to follow and logical.

The interface has some problems with the highlighted blue links. Some of them did not work and I got a 'page not found' message. That can be frustrating for the reader. I'm wondering if a glossary could be utilized (instead of the links) to explain what some of these links are supposed to explain.

I found two or three typos, I don't think they were grammatical errors. In one case I think the Canadian spelling and the United States spelling of the word are just different.

This is a very culturally competent book. In today's world, however, one more type of background that would merit delving into is the trans-gender, GLBTQI person. I was glad that there were no stereotypes.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. Since we are becoming more interprofessional, I liked that we saw what the phlebotomist and other ancillary personnel (mostly different technicians) did. I think that it could become even more interdisciplinary so colleges and universities could have more interprofessional education- courses or simulations- with the addition of the nurse using social work, nutrition, or other professional health care majors.

Reviewed by Catherine J. Grott, Interim Director, Health Administration Program, TRAILS on 5/5/19

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this. read more

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this.

The book is accurate, however it has numerous broken online links.

Relevance/Longevity rating: 3

The content is very relevant, but some links are out-dated. For example, WHO Guidelines for Safe Surgery 2009 (p. 186) should be updated.

The book is written in clear and concise language. The side stories about the healthcare workers make the text interesting.

The book is consistent in terms of terminology and framework. Some terms that are emphasized in one case study are not emphasized (with online links) in the other case studies. All of the case studies should have the same words linked to online definitions.

Modularity rating: 3

The book can easily be parsed out if necessary. However, the way the case studies have been written, it's evident that different authors contributed singularly to each case study.

The organization and flow are good.

Interface rating: 1

There are numerous broken online links and "pages not found."

The grammar and punctuation are correct. There are two errors detected: p. 120 a space between the word "heart" and the comma; also a period is needed after Dr (p. 113).

I'm not quite sure that the social worker (p. 119) should comment that the patient and partner are "very normal people."

There are roughly 25 broken online links or "pages not found." The BC & Canadian Guidelines (p. 198) could also include a link to US guidelines to make the text more universal . The basilar crackles (p. 166) is very good. Text could be used compare US and Canadian healthcare. Text could be enhanced to teach "soft skills" and interdepartmental communication skills in healthcare.

Reviewed by Lindsey Henry, Practical Nursing Instructor, Fletcher on 5/1/19

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning... read more

As a seasoned nurse, I believe that the content regarding pathophysiology and treatments used in the case studies were accurate. I really appreciated how many of the treatments were also explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse.

The case studies are up to date and correlate with the current time period. They are easily understood.

I really loved how several important medical terms, including specific treatments were highlighted to alert the reader. Many interventions performed were also explained further, which is great to enhance learning for the nursing student or novice nurse. Also, with each scenario, a background and history of the patient is depicted, as well as the perspectives of the patient, patients family member, and the primary nurse. This really helps to give the reader a full picture of the day in the life of a nurse or a patient, and also better facilitates the learning process of the reader.

These case studies are consistent. They begin with report, the patient background or updates on subsequent days, and follow the patients all the way through discharge. Once again, I really appreciate how this book describes most if not all aspects of patient care on a day to day basis.

Each case study is separated into days. While they can be divided to be assigned at different points within the course, they also build on each other. They show trends in vital signs, what happens when a patient deteriorates, what happens when they get better and go home. Showing the entire process from ER admit to discharge is really helpful to enhance the students learning experience.

The topics are all presented very similarly and very clearly. The way that the scenarios are explained could even be understood by a non-nursing student as well. The case studies are very clear and very thorough.

The book is very easy to navigate, prints well on paper, and is not distorted or confusing.

I did not see any grammatical errors.

Each case study involves a different type of patient. These differences include race, gender, sexual orientation and medical backgrounds. I do not feel the text was offensive to the reader.

I teach practical nursing students and after reading this book, I am looking forward to implementing it in my classroom. Great read for nursing students!

Reviewed by Leah Jolly, Instructor, Clinical Coordinator, Oregon Institute of Technology on 4/10/19

Good variety of cases and pathologies covered. read more

Good variety of cases and pathologies covered.

Content Accuracy rating: 2

Some examples and scenarios are not completely accurate. For example in the DVT case, the sonographer found thrombus in the "popliteal artery", which according to the book indicated presence of DVT. However in DVT, thrombus is located in the vein, not the artery. The patient would also have much different symptoms if located in the artery. Perhaps some of these inaccuracies are just typos, but in real-life situations this simple mistake can make a world of difference in the patient's course of treatment and outcomes.

Good examples of interprofessional collaboration. If only it worked this way on an every day basis!

Clear and easy to read for those with knowledge of medical terminology.

Good consistency overall.

Broken up well.

Topics are clear and logical.

Would be nice to simply click through to the next page, rather than going through the table of contents each time.

Minor typos/grammatical errors.

No offensive or insensitive materials observed.

Reviewed by Alex Sargsyan, Doctor of Nursing Practice/Assistant Professor , East Tennessee State University on 10/8/18

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study. read more

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study.

Overall the book is accurately depicting the clinical environment. There are numerous references to external sites. While most of them are correct, some of them are not working. For example Homan’s test link is not working "404 error"

Book is relevant in its current version and can be used in undergraduate and graduate classes. That said, the longevity of the book may be limited because of the character of the clinical education. Clinical guidelines change constantly and it may require a major update of the content.

Cases are written very clearly and have realistic description of an inpatient setting.

The book is easy to read and consistent in the language in all eight cases.

The cases are very well written. Each case is subdivided into logical segments. The segments reflect different setting where the patient is being seen. There is a flow and transition between the settings.

Book has eight distinct cases. This is a great format for a book that presents distinct clinical issues. This will allow the students to have immersive experiences and gain better understanding of the healthcare environment.

Book is offered in many different formats. Besides the issues with the links mentioned above, overall navigation of the book content is very smooth.

Book is very well written and has no grammatical errors.

Book is culturally relevant. Patients in the case studies come different cultures and represent diverse ethnicities.

Reviewed by Justin Berry, Physical Therapist Assistant Program Director, Northland Community and Technical College, East Grand Forks, MN on 8/2/18

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles, interprofessional roles, when to initiate communication with other healthcare practitioners due to a change in patient status, and treatment ideas. Some additional patient information, such as lab values, would have been beneficial to include.

Case study information is accurate and unbiased.

Content is up to date. The case studies are written in a way so that they will not be obsolete soon, even with changes in healthcare.

The case studies are well written, and can be utilized for a variety of classroom assignments, discussions, and projects. Some additional lab value information for each patient would have been a nice addition.

The case studies are consistently organized to make it easy for the reader to determine the framework.

The text is broken up into eight different case studies for various patient diagnoses. This design makes it highly modular, and would be easy to assign at different points of a course.

The flow of the topics are presented consistently in a logical manner. Each case study follows a patient chronologically, making it easy to determine changes in patient status and treatment options.

The text is free of interface issues, with no distortion of images or charts.

The text is not culturally insensitive or offensive in any way. Patients are represented from a variety of races, ethnicities, and backgrounds

This book would be a good addition for many different health programs.

Reviewed by Ann Bell-Pfeifer, Instructor/Program Director, Minnesota State Community and Technical College on 5/21/18

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical laboratory technologists, medical radiology technologists, and respiratory therapists and their roles in caring for patients. Most of the overview is accurate. One suggestion is to provide an embedded radiologist interpretation of the exams which are performed which lead to the patients diagnosis.

Overall the book is accurate. Would like to see updates related to the addition of direct radiography technology which is commonly used in the hospital setting.

Many aspects of medicine will remain constant. The case studies seem fairly accurate and may be relevant for up to 3 years. Since technology changes so quickly in medicine, the CT and x-ray components may need minor updates within a few years.

The book clarity is excellent.

The case stories are consistent with each scenario. It is easy to follow the structure and learn from the content.

The book is quite modular. It is easy to break it up into cases and utilize them individually and sequentially.

The cases are listed by disease process and follow a logical flow through each condition. They are easy to follow as they have the same format from the beginning to the end of each case.

The interface seems seamless. Hyperlinks are inserted which provide descriptions and references to medical procedures and in depth definitions.

The book is free of most grammatical errors. There is a place where a few words do not fit the sentence structure and could be a typo.

The book included all types of relationships and ethnic backgrounds. One type which could be added is a transgender patient.

I think the book was quite useful for a variety of health care professionals. The authors did an excellent job of integrating patient cases which could be applied to the health care setting. The stories seemed real and relevant. This book could be used to teach health care professionals about integrated care within the emergency department.

Reviewed by Shelley Wolfe, Assistant Professor, Winona State University on 5/21/18

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should be noted that the authors include a statement that conveys that this text is not like traditional textbooks and is not meant to be read in a linear fashion. This allows the educator more flexibility to use the text as a supplement to enhance learning opportunities.

The content of the text appears accurate and unbiased. The “five overarching learning objectives” provide a clear aim of the text and the educator is able to glean how these objectives are captured into each of the case studies. While written for the Canadian healthcare system, this text is easily adaptable to the American healthcare system.

Overall, the content is up-to-date and the case studies provide a variety of uses that promote longevity of the text. However, not all of the blue font links (if using the digital PDF version) were still in working order. I encountered links that led to error pages or outdated “page not found” websites. While the links can be helpful, continued maintenance of these links could prove time-consuming.

I found the text easy to read and understand. I enjoyed that the viewpoints of all the different roles (patient, nurse, lab personnel, etc.) were articulated well and allowed the reader to connect and gain appreciation of the entire healthcare team. Medical jargon was noted to be appropriate for the intended audience of this text.

The terminology and organization of this text is consistent.

The text is divided into 8 case studies that follow a similar organizational structure. The case studies can further be divided to focus on individual learning objectives. For example, the case studies could be looked at as a whole for discussing communication or could be broken down into segments to focus on disease risk factors.

The case studies in this text follow a similar organizational structure and are consistent in their presentation. The flow of individual case studies is excellent and sets the reader on a clear path. As noted previously, this text is not meant to be read in a linear fashion.

This text is available in many different forms. I chose to review the text in the digital PDF version in order to use the embedded links. I did not encounter significant interface issues and did not find any images or features that would distract or confuse a reader.

No significant grammatical errors were noted.

The case studies in this text included patients and healthcare workers from a variety of backgrounds. Educators and students will benefit from expanding the case studies to include discussions and other learning opportunities to help develop culturally-sensitive healthcare providers.

I found the case studies to be very detailed, yet written in a way in which they could be used in various manners. The authors note a variety of ways in which the case studies could be employed with students; however, I feel the authors could also include that the case studies could be used as a basis for simulated clinical experiences. The case studies in this text would be an excellent tool for developing interprofessional communication and collaboration skills in a variety healthcare students.

Reviewed by Darline Foltz, Assistant Professor, University of Cincinnati - Clermont College on 3/27/18

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks... read more

The book appears to be accurate. Although one of the learning outcomes is as follows: "Demonstrate an understanding of the Canadian healthcare delivery system.", I did not find anything that is ONLY specific to the Canadian healthcare delivery system other than some of the terminology, i.e. "porter" instead of "transporter" and a few french words. I found this to make the book more interesting for students rather than deter from it. These are patient case studies that are relevant in any country.

The content is up-to-date. Changes in medical science may occur, i.e. a different test, to treat a diagnosis that is included in one or more of the case studies, however, it would be easy and straightforward to implement these changes.

This book is written in lucid, accessible prose. The technical/medical terminology that is used is appropriate for medical and allied health professionals. Something that would improve this text would to provide a glossary of terms for the terms in blue font.

This book is consistent with current medical terminology

This text is easily divided into each of the 6 case studies. The case studies can be used singly according to the body system being addressed or studied.

Because this text is a collection of case studies, flow doesn't pertain, however the organization and structure of the case studies are excellent as they are clear and easy to read.

There are no distractions in this text that would distract or confuse the reader.

I did not identify any grammatical errors.

This text is not culturally insensitive or offensive in any way and uses patients and healthcare workers that are of a variety of races, ethnicities and backgrounds.

I believe that this text would not only be useful to students enrolled in healthcare professions involved in direct patient care but would also be useful to students in supporting healthcare disciplines such as health information technology and management, medical billing and coding, etc.

Introduction

Case Study #1: Chronic Obstructive Pulmonary Disease (COPD)

Learning Objectives
Patient: Erin Johns
Emergency Room

Case Study #2: Pneumonia

Day 0: Emergency Room
Day 1: Emergency Room
Day 1: Medical Ward
Day 2: Medical Ward
Day 3: Medical Ward
Day 4: Medical Ward

Case Study #3: Unstable Angina (UA)

Patient: Harj Singh

Case Study #4: Heart Failure (HF)

Patient: Meryl Smith
In the Supermarket
Day 0: Medical Ward

Case Study #5: Motor Vehicle Collision (MVC)

Patient: Aaron Knoll
Crash Scene
Operating Room
Post Anaesthesia Care Unit (PACU)
Surgical Ward

Case Study #6: Sepsis

Patient: George Thomas
Sleepy Hollow Care Facility

Case Study #7: Colon Cancer

Patient: Fred Johnson
Two Months Ago
Pre-Surgery Admission

Case Study #8: Deep Vein Thrombosis (DVT)

Patient: Jamie Douglas

Appendix: Overview About the Authors

Ancillary Material

About the book.

Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation.

The case studies can be used online in a learning management system, in a classroom discussion, in a printed course pack or as part of a textbook created by the instructor. This flexibility is intentional and allows the educator to choose how best to convey the concepts presented in each case to the learner.

Because these case studies were primarily developed for an electronic healthcare system, they are based predominantly in an acute healthcare setting. Educators can augment each case study to include primary healthcare settings, outpatient clinics, assisted living environments, and other contexts as relevant.

About the Contributors

Glynda Rees teaches at the British Columbia Institute of Technology (BCIT) in Vancouver, British Columbia. She completed her MSN at the University of British Columbia with a focus on education and health informatics, and her BSN at the University of Cape Town in South Africa. Glynda has many years of national and international clinical experience in critical care units in South Africa, the UK, and the USA. Her teaching background has focused on clinical education, problem-based learning, clinical techniques, and pharmacology.

Glynda‘s interests include the integration of health informatics in undergraduate education, open accessible education, and the impact of educational technologies on nursing students’ clinical judgment and decision making at the point of care to improve patient safety and quality of care.

Faculty member in the critical care nursing program at the British Columbia Institute of Technology (BCIT) since 2003, Rob has been a critical care nurse for over 25 years with 17 years practicing in a quaternary care intensive care unit. Rob is an experienced educator and supports student learning in the classroom, online, and in clinical areas. Rob’s Master of Education from Simon Fraser University is in educational technology and learning design. He is passionate about using technology to support learning for both faculty and students.

Part of Rob’s faculty position is dedicated to providing high fidelity simulation support for BCIT’s nursing specialties program along with championing innovative teaching and best practices for educational technology. He has championed the use of digital publishing and was the tech lead for Critical Care Nursing’s iPad Project which resulted in over 40 multi-touch interactive textbooks being created using Apple and other technologies.

Rob has successfully completed a number of specialist certifications in computer and network technologies. In 2015, he was awarded Apple Distinguished Educator for his innovation and passionate use of technology to support learning. In the past five years, he has presented and published abstracts on virtual simulation, high fidelity simulation, creating engaging classroom environments, and what the future holds for healthcare and education.

Janet Morrison is the Program Head of Occupational Health Nursing at the British Columbia Institute of Technology (BCIT) in Burnaby, British Columbia. She completed a PhD at Simon Fraser University, Faculty of Communication, Art and Technology, with a focus on health information technology. Her dissertation examined the effects of telehealth implementation in an occupational health nursing service. She has an MA in Adult Education from St. Francis Xavier University and an MA in Library and Information Studies from the University of British Columbia.

Janet’s research interests concern the intended and unintended impacts of health information technologies on healthcare students, faculty, and the healthcare workforce.

She is currently working with BCIT colleagues to study how an educational clinical information system can foster healthcare students’ perceptions of interprofessional roles.

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Medical Case Study Template

Utilize our Medical Case Study Template for systematic documentation and analysis of patient cases, enhancing learning and clinical practice.

By Emma Hainsworth on Feb 29, 2024.

Fact Checked by Ericka Pingol.

What is a Medical Case Study Template?

A Medical Case Study Template is a systematic tool used primarily by healthcare professionals and students to document, analyze, and present individual patient cases. It serves as a structured guide, ensuring that all critical aspects of the case are captured and discussed in a standardized format. This includes patient information, clinical history, diagnostic assessments, treatments, and outcomes.

The template typically starts with a title and a brief abstract summarizing the case. It progresses through detailed sections covering patient demographics, symptoms, examination findings, and the results of any diagnostic tests. Treatment plans and their outcomes are also meticulously documented.

One of the key purposes of this template is educational. It facilitates learning by providing a comprehensive overview of real-life clinical scenarios, encouraging critical thinking and analysis. It's also used in medical research and literature to share clinical experiences and insights, contributing to the broader medical community's understanding of various conditions and treatments.

Using a Medical Case Study Template ensures a thorough and uniform approach to case documentation, which is essential for effective learning, discussion, and advancement in medical practice. It emphasizes the importance of detail and accuracy in clinical reporting, enhancing both educational value and patient care.

Printable Medical Case Study Template

Download this Medical Case Study Template used primarily by healthcare professionals and students to document, analyze, and present individual patient cases.

How does it work?

Here's a step-by-step guide to accessing and using our Medical case study template:

Step 1: Access and download the Medical Case Study Template

Click the link on this page to download and access the Medical Case Study Template. The template is available in a user-friendly PDF format, allowing for easy digital viewing and interaction.

You can print the template if a physical copy is preferred for note-taking or group discussions. This is especially useful in educational settings or during team meetings.

Step 2: Understand the structure of the template

Review the template to understand its various sections, which include patient information, clinical history, diagnosis, treatment, and outcome.

Note the specific details required in each section, such as demographic data, symptoms, test results, and follow-up care. Understanding these components is crucial for consistency and comprehensiveness in case documentation.

Step 3: Utilize the template for case documentation

Use the template to systematically record all relevant details of a patient case. This might be for educational purposes, research, or clinical documentation.

Regularly update the template with new information or follow-up details. This is important for tracking the case's progression and observing treatments' effectiveness.

Keep in mind that each patient case is unique. The template should be adaptable to accommodate the specificities of different medical scenarios.

Step 4: Review and share the documented case

Use the documented case for peer discussions, educational sessions, or team reviews. The structured format of the template facilitates easy sharing and collaborative analysis.

Encourage feedback on the documented case to enhance learning and improve clinical practices. The template can be a tool for reflective practice and continuous professional development.

By following these steps, healthcare professionals, educators, and students can effectively use the Medical Case Study Template for a range of purposes. This resource is invaluable for documenting individual cases and as a tool for education, research, and collaborative learning in the medical field.

Medical Case Study Example (sample)

We have provided a comprehensive example as a downloadable PDF to help users effectively utilize the Medical Case Study Template. This sample case study is a practical guide, demonstrating how to document and analyze a clinical case in a structured and detailed manner. It is especially useful for medical professionals, educators, and students in the healthcare field.

The Medical Case Study PDF Example, readily available for download and review, showcases the practical application of the case study template in a real-world clinical setting. The example features a case study highlighting how to systematically record patient information, clinical history, diagnostic assessments, treatment plans, and outcomes.

You can access this valuable resource by either previewing the sample provided below or clicking the "Download Example PDF" button.

Download this Medical Case Study Template example:

When would you use this Template?

The Medical Case Study Template is an invaluable resource primarily used by healthcare professionals, medical students, and educators in various clinical and educational settings. Its application is particularly relevant and beneficial in several key scenarios.

Clinical education and training

Medical educators often use this template to teach students about real-life medical cases. It provides a structured approach to case analysis, encouraging students to examine all aspects of patient care, from diagnosis to treatment and follow-up. This methodical approach is crucial in developing critical thinking and diagnostic skills.

Peer learning and discussion

The template is used among healthcare professionals as a basis for case discussions, often in grand rounds or peer review meetings. It allows practitioners to present complex cases to colleagues, fostering collaborative analysis and discussion. This shared learning experience can lead to improved patient care strategies and a deeper understanding of rare or challenging cases.

Research and case reporting

When documenting unique or particularly instructive cases for medical research or publication, the Medical Case Study Template provides a comprehensive format. It ensures that all relevant details are systematically presented, making the case valuable for the wider medical community. This is especially important when contributing to medical journals or databases.

Quality improvement initiatives

In quality assurance and improvement activities within healthcare settings, this template can be used to analyze cases that highlight systemic issues or successes. It aids in identifying areas for improvement in patient care processes and protocols.

Personal professional development

For individual healthcare practitioners, the template serves as a tool for reflecting on challenging cases, allowing for self-assessment and continuous professional development.

Benefits of using this template ?

Using a Medical Case Study Template offers several significant benefits:

Standardized documentation: The template provides a uniform structure for documenting patient cases. This standardization is crucial for ensuring that all relevant details are consistently recorded and easy to find, which is particularly beneficial when multiple healthcare professionals review cases.
Enhanced educational value: For medical students and trainees, the template is an educational tool that promotes a thorough understanding of clinical cases. It encourages a holistic view of patient care, encompassing diagnosis, treatment, and follow-up, and helps in developing critical thinking and analytical skills.
Improved communication: When discussing patient cases with peers or in academic settings, the template aids in clear and concise communication. It ensures that all necessary information is presented in an organized manner, facilitating better understanding and discussion among medical professionals.
Quality of care and patient safety: By systematically documenting and reviewing patient cases, healthcare providers can identify trends, successes, and areas for improvement in treatment protocols. This can lead to enhanced patient safety and overall quality of care.
Facilitates research and publication: The template is invaluable for practitioners looking to publish case reports in medical journals. It ensures that the case is documented in a comprehensive and systematic manner, meeting the standards required for academic and research publications.
Professional development: Regular use of the template encourages practitioners to reflect on their clinical practice, helping them to identify areas for professional growth and development.
Consistency in case analysis: The template provides a consistent framework for analyzing and discussing patient cases. This consistency is essential for comparative analysis and for understanding the nuances of different cases.
Time efficiency: With a set structure in place, healthcare professionals can save time in documenting and reviewing cases, as they do not have to create a new format each time.

Commonly asked questions

A Medical Case Study Template is a structured document used to record and analyze patient cases in a systematic and detailed manner. It helps in documenting patient history, diagnosis, treatment, and follow-up, ensuring all crucial aspects of the case are covered.

Medical professionals, including doctors, nurses, and therapists, as well as medical students and educators, can benefit from using this template. It's also useful for researchers and clinicians involved in case studies for publication or presentation.

The template ensures comprehensive documentation of patient cases, which aids in better understanding and analyzing the patient's condition and treatment outcomes. This thorough approach can lead to more informed and effective patient care strategies.

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Learn about the Accommodation Eye Test, PERRLA, and signs of accommodative insufficiency in our comprehensive eye health guide.

List of Coping Skills for Addiction PDF

Download our List of Coping Skills for Addiction PDF to develop healthy coping skills and foster a positive attitude toward recovery.

DSM 5 Criteria for OCD

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DSM 5 Criteria for Anorexia Nervosa

Learn the DSM 5 criteria for Anorexia Nervosa, including diagnostic features and characteristic symptoms. Get a free PDF download for your reference.

Psychosexual Evaluation

Explore our Psychosexual Evaluation: A comprehensive tool for assessing sexual behaviors and risks, aiding legal decisions, treatment plans, and risk assessment.

Vitamin Chart

Discover the importance of vitamins for optimal health with our comprehensive Vitamin Chart. Learn about functions, sources, and dietary recommendations.

Medical Needs Form

Download Carepatron's free PDF example of a Medical Needs Form to help organize and track important medical information for individuals. Keep your medical needs organized with this helpful form.

Conduct Disorder Test

Assessing conduct disorder in individuals is crucial for effective intervention. Download Carepatron's free PDF example of a Conduct Disorder Test and learn how to use it effectively.

Self-care Inventory

Try our Self-care Inventory Template, designed to help healthcare professionals and patients assess and improve self-care habits. Treat yourself to a better you.

DSM 5 Criteria for Binge Eating Disorder

Explore the DSM-5 Criteria for Binge Eating Disorder with our comprehensive template. Understand the diagnosis, impact, and treatment options for BED.

Height Weight Charts

Learn about height-weight charts and their use in healthcare practice. Find out your ideal weight and stay healthy!

Glasgow Coma Scale

The Glasgow Coma Scale (GCS) dates back to the 1970s and has become one of the most widely accepted measurements of impairment following brain injury. What better way to start using the GCS in your practice than with Carepatron’s free PDF GCS template download.

A1C Goals By Age Chart

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Weight Height Chart For Women

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Rhomboid Manual Muscle Test

Learn how to detect Rhomboid muscle weakness by conducting the Rhomboid Manual Muscle Test!

NANDA Nursing Care Plan

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Fever Temperature Chart

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Manual Muscle Testing

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Pain Level Chart

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Admission Nursing Note

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ALT Blood Test

Discover the ALT Blood Test, including what it is, how it works, when to use it, and interpret results. Free ALT Blood Test example available for download.

Palliative Performance Scale

Learn about the Palliative Performance Scale and its application in hospice care. Download a free PDF template and follow our guide to using the PPS effectively.

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Case Studies

EDTA-Induced Pseudothrombocytopenia up to 9 Months after Initial COVID-19 Infection Associated with Persistent Anti-SARS-CoV-2 IgM/IgG Seropositivity

A Novel Mutation of the Membrane Metallo-Endopeptidase Gene Related to Late-Onset Hereditary Polyneuropathy: Case Report and Review of the Literature

An African American Male Patient with Rare Type B Insulin Resistance Syndrome

Unexpectedly Abnormal Electrolytes in a 60 Year Old Man with Dementia

Massive Transfusion Protocol in a 69 Year Old Woman with Alloantibodies

From A to AB: A Caucasian Mother with High Anti-B Titer Causing Hemolytic Disease of the Newborn

Achondroplasia—First Report from India of a Rare FGFR3 Gene Variant

Analysis of Multiple Bands on Serum Protein Immunofixation Electrophoresis: Challenge in Interpretation of Clonality in a Patient with Light Chain–Predominant Multiple Myeloma

Loss and Reappearance of A Antigen After Chemotherapy Leading to Blood Group Discrepancy in Acute Myeloid Leukemia: A Case Report

Sky High or Undetectable? A Patient with Discordant Hemoglobin A1c

Lymphocyte Aggregation in Low-Grade B-Cell Lymphoma

Hemolytic Disease of the Fetus and Newborn Caused by Maternal Autoantibody with Mimicking Anti-E Specificity

The Impact of Mass Spectrometry on Patients’ Medical and Nonmedical Lives

Daratumumab Interference in Flow Cytometry Producing a False Kappa Light Chain Restriction in Plasma Cells

Monocytic Acute Myeloid Leukemias with KM2TA Translocations to Chromosome 17q that May Clinically Mimic Acute Promyelocytic Leukemia

Detection of a Cryptic EP300/ZNF384 Gene Fusion by Chromosomal Microarray and Next-Generation Sequencing Studies in a Pediatric Patient with B-Lymphoblastic Leukemia

A Hemolytic Transfusion Reaction Caused by an Unexpected Le b Antibody

Cording in Disseminated Mycobacterium chelonae Infection in an Immunocompromised Patient

Acute Hemolytic Transfusion Reaction Due to Pooled Platelets: A Rare but Serious Adverse Event

Unexpected Short-Tandem-Repeat Patterns in Posttransplant Chimerism Testing: Investigation of 3 Cases with Help from Forensic Science

Phenotypes Associated with 16p11.2 Copy Number Gains and Losses at a Single Institution

Severe Platelet Transfusion Refractoriness in Association with Antibodies Against CD36

Interference of M-protein on Thrombin Time Test: A Case Report

Paradoxical Hypercholesterolemia in an Otherwise Healthy Adult Man

Persistent Rivaroxaban Effect Due to Impaired Renal Clearance and Medication Effects

Pulmonary Coccidioidomycosis Mimicking Aspergillosis Fungus Ball

Post-Transfusion Purpura Mimicking Idiopathic Thrombocytopenic Purpura: A Case Report

Benign Pancreatic Hyperenzymemia, Also Known as Gullo’s Syndrome

Anti-M–Induced Delayed Hemolytic Transfusion Reaction

Mixed Phenotype Acute Leukemia that Evolved from Myelodysplastic Syndrome with Excess Blasts

Unexpectedly Weak Anti-B in 2 Group O Pediatric Patients on Parenteral Nutrition and Disease Specific Supplemental Enteral Feeds

α-1 Antitrypsin Genotype-Phenotype Discrepancy in a 42-Year-Old Man Who Carries the Null-Allele

A Novel Pathogenic CALR Exon 9 Mutation in a Patient with Essential Thrombocythemia

A 70-Year-Old Female with Unexpected Platelet Function Testing Results

Myelodysplastic Syndrome/Myeloproliferative Neoplasm with Ring Sideroblasts and Thrombocytosis with Cooccurrent SF3B1 and MPLGene Mutations: A Case Report and Brief Review of the Literature

BCR-ABL1-like B-Lymphoblastic Leukemia/Lymphoma with FOXP1-ABL1 Rearrangement: Comprehensive Laboratory Identification Allowing Tyrosine Kinase Inhibitor Use

A Case of Chronic Thrombocytopenia in a 17-Year-Old Female

Blood Donation During Pregnancy Due to Anti-Ku Hemolytic Disease of the Fetus and Newborn

Disseminated Hormographiella aspergillata Infection with Lung and Brain Involvement after Allogenic Hematopoietic Stem-Cell Transplantation in a 54-Year-Old Man

Cryoglobulinemia as a Possible Primer for TRALI: Report of a Case

Case Report and Literature Review of Nodular Hiradenoma, a Rare Adnexal Tumor That Mimics Breast Carcinoma, in a 20-Year-Old Woman

Monitoring Fondaparinux in the Setting of Antithrombin Deficiency

Iron Overload in an HFE Heterozygous Carrier: A Case Report and Literature Review

Differential Diagnosis of a Patient with Lysosomal Acid Lipase Deficiency: A Case Report

Severe Underestimation of Serum Na following IVIG Treatment

Interference by Rheumatoid Factor in Immunoglobulin M-Class Herpes Simplex Virus Types 1 + 2 Immunoassays

The Diagnostic Challenge of Acquired Thrombotic Thrombocytopenic Purpura in Children: Case Report and Review of the Literature

Rat Poisoning: A Challenging Diagnosis With Clinical and Psychological Implications

A Positive Urine Alcohol with Negative Urine Ethyl-Glucuronide

Critically Elevated Potassium in a 55-Year-Old Female With Chronic Lymphocytic Leukemia

Establishing the Cause of Anemia in a Premature Newborn Infant

Lymph Node With Extensive Involvement by Cryptococcus Shortly Following Liver Transplantation

Acute Liver Failure in an Adolescent Male Induced by Human Herpesvirus 6 (HHV-6): A Case Report With Literature Review

Developmental Defects Associated With DNA Copy Number Gain of Chromosome 2q33.1: A Case Report and Review of Literature

A Noninvasive Rhizopus Infection With a Bladder Fungal Ball in a Patient With Poorly Controlled Diabetes Mellitus

A Case of Hodgkin Lymphoma Mimicking Lymphomatoid Granulomatosis Diagnosed at Autopsy

Multiple Myeloma: The Case of the Disappearing Band

Detection of an Underlying 22q11.2 Duplication in a Female Neonate With Trisomy 18

Acute Myeloid Leukemia With a Rare t(7;14)(q21;q32) and Trisomy 4 With Poor Clinical Outcome: A Case Report

Histoplasmosis in Pleural Effusion in a 23-Year-Old Man With Mixed-Phenotype Acute Leukemia

R634W KIT Mutation in an Adult With Systemic Mastocytosis

Acute Hemolytic Transfusion Reaction Caused by a Red Cell Antibody That Was Missed by Pretransfusion Testing Using Tube Method

Intra-Pericardial Use of Recombinant Factor VIIa in a Patient With Acute Hemorrhagic Pericardial Effusion Following Transcutaneous Aortic Valve Replacement—A Case Report

A Food Debris–Like Component in the Urine Sediment From a Urostomy Pouch

Variable Potassium Concentrations: Which Is Right and Which Is Wrong?

What Clinical Laboratorians Should Do in Response to Extremely Low Hemoglobin A1c Results

Warm Autoimmune Hemolytic Anemia and Direct Antiglobulin Testing With a False-Negative Result in a 53-Year-Old Man

A Case of Unexplained Cerebral Sinus Thrombosis in a 22-Year-Old Obese Caucasian Woman

Pasteurella multocida Bacteremia With Associated Knee Arthroplasty Infection in an 80-Year-Old Caucasian Man

A Case Report of May-Hegglin Anomaly in a 33-Year-Old White Woman

Clostridium Sordellii as an Uncommon Cause of Fatal Toxic Shock Syndrome in a Postpartum 33-Year-Old Asian Woman

Trichosporon loubieri Fungemia in a 39-Year-Old Caucasian Woman With B-Cell Lymphoblastic Leukemia

Folate Insufficiency Due to Celiac Disease in a 49-Year-Old Woman of Southeast Asian-Indian Ethnicity

Rhizobium Radiobacter Infection in a 27-Year-Old African American Woman With Munchausen Syndrome

Naegleria fowleri That Induces Primary Amoebic Meningoencephalitis: Rapid Diagnosis and Rare Case of Survival in a 12-Year-Old Caucasian Girl

Leukemic Transdifferentiation of Follicular Lymphoma Into an Acute Histiocytic Leukemia in a 52-Year-Old Caucasian Woman

Skin Rash and Microscopic Hematuria in a 10-Year-Old Caucasian Male

Hematogones With Lambda Light Chain Restriction in a 4-Year-Old Boy With Burkitt Lymphoma: A Potential Diagnostic Pitfall

Reciprocal Microduplication of the Williams-Beuren Syndrome Chromosome Region in a 9-Year-Old Omani Boy

A Case of Sepsis in a 92-Year-Old Korean Woman Caused by Aerococcus urinae and Identified by Sequencing the 16S Ribosomal RNA Gene

Concurrent and Clonally Related Pediatric Follicular Lymphoma and Burkitt Lymphoma in a 5-Year-Old Boy

Sudden Development of Thrombocytopenia After Reversal of Anticoagulation for Surgery

Cervical FISH Testing for Triage and Support of Challenging Diagnoses: A Case Study of 2 Patients

Genotyping and Resolution of a Case of Osteomyelitis in a 16-Month-Old Boy of Hispanic/African American Ethnicity

Brodifacoum Inhalation and its Clinical Manifestations in a 21-Year-Old Caucasian Man

Selected Noninvasive Markers in Diagnosing Liver Diseases

Nitrous Oxide Abuse and Vitamin B12 Action in a 20-Year-Old Woman: A Case Report

Elevated CA125 Levels in a 72-Year-Old Ethnic Indian Patient: A Diagnostic Pointer Toward Tuberculosis?

B Lymphoblastic Leukemia With a Novel t(11;15) (q23;q15) and Unique Burkittoid Morphologic and Immunophenotypic Findings in a 9-Year-Old Boy

Mucoepidermoid Carcinoma in a 33-Year-Old White Man

Invasive Paget Disease of the Nipple of Luminal-B Subtype With Axillary Lymph Node Metastasis in a 60-Year-Old White Woman

Trichosporon asahii Infection in a Patient with Metastatic Prostate Cancer as an Example of an Emerging Fungal Pathogen

Differentiation Between Sickle Cell Anemia and S/β 0 Thalassemia

Acute Precursor B-Cell Lymphoblastic Leukemia in a 1-Year-Old White Male: Diagnostic Evaluation and Flow Cytometric Analysis

Development and Detection of Kidd Antibodies

Low-Grade Adenosquamous Carcinoma of the Breast Developing Around a Localization Wire Fragment

Case Report of Autopsy and Placental Examination After Radiofrequency Ablation of an Acardiac Twin

Persistent Human Chorionic Gonadotropin After Methotrexate Treatment and an Emergency Surgical Procedure for Ectopic Pregnancy

Encrusted Cystitis Secondary to Corynebacterium glucuronolyticum in a 57-Year-Old Man Without Predisposing Factors

Thyroid Cancer and T Lymphoblastic Leukemia in Crohn Disease: A Case Report and Literature Review

A Nontoxic Case of Vitamin D Toxicity

An Unexpected Emergency Request for Glucose-6-Phosphate Dehydrogenase Testing in a 9-Year-Old African American Boy

Cytologic Features of Metanephric Adenoma of the Kidney: Case Report and Review of the Literature

Primary CNS T-Cell Lymphoma of the Spinal Cord: Case Report and Literature Review

Benzodiazepine in a Urine Specimen Without Drug Metabolites

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Page 1 of 142

Non-traumatic complete cervical spine dislocation with severe fixed kyphosis: successful multidisciplinary approach to a challenging case

To our knowledge, there is no previous report in the literature of non-traumatic neglected complete cervical spine dislocation characterized by anterior spondyloptosis of C4, extreme head drop, and irreducible...

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Post-radiation lichen planus: a case report and review of the literature

Lichen planus is a T-cell mediated inflammatory disorder of the skin and mucus membranes and is a rare complication of external beam radiation.

Atypical lipoma of the right piriformis muscle: a case report and review of the literature

Piriformis muscle mass is rare, which is particular for intrapiriformis lipoma. Thus far, only 11 cases of piriformis muscle mass have been reported in the English literature. Herein, we encountered one patien...

Antidiuretic hormone deficiency secondary to inactive hydrocephalus: a case report

Diabetes insipidus is a syndrome characterized by polyuria, which is almost always associated with polydipsia. The most frequent cause is central diabetes insipidus, which is the result of an inadequate secret...

Conventional herniorrhaphy followed by laparoscopic appendectomy for a variant of Amyand’s hernia: a case report

Amyand’s hernia (AH) is an appendix (with or without acute inflammation) trapped within an inguinal hernia. Most AH with acute appendicitis had a preexisting appendix within the hernia sac. We herein report a ...

Plasmapheresis in thyrotoxicosis: a single-center case series

Plasmapheresis represent an alternative therapeutic option for hyperthyroidism with thyroid storm or refractory cases. It provides a rapid decrease in plasma thyroid hormones and anti-thyroid antibodies. The a...

Post molar choriocarcinoma with solitary renal metastasis in the absence of primary uterine tumor: a case report and review of the literature

Choriocarcinoma is a rare and highly malignant form of gestational trophoblastic disease that may develop following pregnancy, abortion, or a hydatiform mole. Renal metastatic involvement by post molar chorioc...

Atypical Duplex appendix arising from the ascending colon: a case report

Duplex or vermiform appendix refers to the presence of an appendix beside the naturally occurring one. Although, duplex appendix emerges from the caecum most of the time, yet it is encountered in other parts o...

Pancreaticopleural fistula causing pleural effusion: a case report and review of the literature

Pancreaticopleural fistula is a rare complication of pancreatitis and poses diagnostic and therapeutic challenges. This case report sheds light on the unique challenges posed by pancreaticopleural fistula as a...

Intra-pulmonary migration of a clavicle osteosynthesis pin: a case report

Fractures of the clavicle are common injuries, which often require reduction and internal fixation. Although Kirschner pins have been commonly used to treat these fractures with good results, migration of thes...

Tetralogy of Fallot complicated by multiple cerebral abscesses in a child: a case report

Brain abscesses are rare but potentially fatal condition and can be associated with cyanotic congenital heart disease of which 5–18.7% of these patients that develop cerebral abscess commonly have tetralogy of...

Glucose phosphate isomerase deficiency demasked by whole-genome sequencing: a case report

Glucose-6-phosphate isomerase deficiency is a rare genetic disorder causing hereditary nonspherocytic hemolytic anemia. It is the second most common glycolytic enzymopathy in red blood cells. About 90 cases ar...

Facial cutaneous Rosai-Dorfman disease: a case report

Rosai-Dorfman disease (RDD) is a form of non-Langerhans cell histiocytosis in which the activated histiocytes of the lymph nodes and other organs begin to accumulate following excessive production. Bilateral, ...

Donepezil-induced bradycardia in a schizophrenic patient with comorbid neurocognitive disorder: a case report and review of the literature

Trials of cholinergic and glutamatergic agents have improved cognition and memory for the geriatric schizophrenic population. Donepezil is an acetylcholinesterase inhibitor that improves cognition by preventin...

Metastasis of serous ovarian carcinoma to the breast: a case report and review of the literature

Breast metastasis from primary ovarian cancer is rare, with an estimated frequency of 0.07%. More than 110 cases are reported in the literature of metastatic spread of ovarian cancer to the breast and axilla. ...

Stenotrophomonas maltophilia neonatal sepsis: a case report

Stenotrophomonas maltophilia is a gram-negative bacteria known for causing opportunistic and nosocomial infections in humans. S. maltophilia is an emerging pathogen of concern due to it’s increasing prevalence, d...

Recurrent severe hypocalcemia following chemotherapy regimen changes in advanced breast cancer: two case reports

As an oncologic emergency related to abnormalities in calcium metabolism, hypercalcemia associated with paraneoplastic syndrome and bone metastases is well known. Meanwhile, the incidence of hypocalcemia is lo...

Squamous cell carcinoma malignant transformation in mature cystic teratoma of the ovary: a case report and review of the literature

Mature cystic teratoma of the ovary is classified among the benign ovarian germ cell neoplasms, and its malignant transformation occurs very rarely (in about 2%). As a result of nonspecific signs and symptoms,...

A rare variant of mullerian agenesis: a case report and review of the literature

Menstruation is a developmental milestone and usually marks healthy and normal pubertal changes in females. Menarche refers to the onset of first menstruation in a female. The causes of primary amenorrhea incl...

Botulinum toxin: a new differential diagnosis for a lytic bone lesion

Botulinum toxin, produced by the Gram-positive anaerobe Clostridium botulinum , is composed of seven antigenic subtypes (A, B, C, D, E, F, and G). Currently, only Botulinum toxin type A, commonly referred to as “B...

Effects of dry needling on spasticity, cortical excitability, and range of motion in a patient with multiple sclerosis: a case report

Dry needling is an intervention used by physiotherapists to manage muscle spasticity. We report the effects of three sessions of dry needling on ankle plantar flexor muscle spasticity and cortical excitabilit...

Primary alveolar rhabdomyosarcoma of the brain: a case report

Primary brain rhabdomyosarcoma is a rare primary brain malignancy with few case reports. The vast majority of cases of primary brain rhabdomyosarcoma occur in pediatric patients, and immunohistochemistry can d...

Partial facial duplication (diprosopus): a case report and review of the literature

Diprosopus, or craniofacial duplication, is a rare entity that occurs in approximately 1 in 180,000 to 15 million live births. The degree of duplication varies from complete facial duplication to small facial ...

Treatment of a fractured humerus and partially torn supraspinatus tendon in a professional boxer with liquid platelet-rich fibrin and heat-coagulated albumin gel: a case report

Fractures with delayed healing can be a serious complication, especially for athletes depending on quick return to sports. To our knowledge, no cases of increased healing of delayed union fractures with autolo...

Recurrent bladder leiomyoma: a case report

Bladder leiomyomas are rare benign growths in the bladder, comprising less than 0.5% of bladder tumors with only 250 cases reported globally. They are more common in women. This case involves a 70-year-old wom...

Giant cell tumor of soft tissue involving thyroid gland: a case report and review of the literature

Giant cell tumor of soft tissue is a low malignant uncommon neoplasm, with histologic features and immunophenotype similar to its bone counterpart. Primary giant cell tumor of soft tissue in the thyroid gland ...

Diagnostic dilemma in maxillofacial pathologies: a case series

Head and neck are a site of numerous pathologies with different aetiologies and presentations. Rare pathologies, although infrequent still do exist. Diagnostic dilemma in maxillofacial pathologies can be the m...

Uveal effusion syndrome: a case report

This case report is applicable to the field of ophthalmology because there is a paucity of medical literature related to the clinical presentation, diagnosis, and management of uveal effusion syndrome. This is...

Parenteral nutrition: a life–saving intervention for 4 months in short bowel syndrome—a case report and review of the literature

Short bowel syndrome (SBS) in adults is defined as having less than 180 to 200 cm of remaining small bowel. Many literature sources do not provide precise epidemiological data, and challenges in estimating the...

Oncocytic papillary cystadenoma of the larynx: a case report

Cystadenoma of the salivary glands is a rare benign clinical condition affecting both major and minor salivary glands equally. It constitutes approximately 2% of total neoplasms and 4.2–4.7% of benign formatio...

Aeromonas veronii -associated endogenous endophthalmitis: a case report

Aeromonas veronii is a very rare and highly pathogenic microorganism. We investigate the clinical characteristics and significance of endogenous endophthalmitis caused by Aeromonas veronii in our patient.

Successful management of an advanced interstitial ectopic pregnancy in a resource-limited setting: a case report

Interstitial ectopic pregnancy is an ectopic gestation developing in the uterine part of the fallopian tube. The condition is rare and presents challenges for clinical as well as radiological diagnosis. This c...

Fulminant coronavirus disease 2019 meningitis in Iranian infants: a case series

Pediatric coronavirus disease 2019 infection usually presents with respiratory and gastrointestinal symptoms. In this report we present fulminant meningitis as the main presentation of coronavirus disease 2019...

Acalypha indica induced acute oxidative haemolysis and methaemoglobinaemia: two case reports

Herbal products and traditional remedies are commonly used by individuals worldwide for the management of common ailments, even though most are not without risks. Acalypha indica is a popular medicinal plant cons...

Cannabinoid hyperemesis and pheochromocytoma hypertensive urgency: a case report

This report presents a case of cannabinoid-induced hyperemesis syndrome causing repeated violent retching in a patient with a large (8 cm) adrenal pheochromocytoma resulting in hypertensive urgency.

Sebaceous carcinoma in a 54-year-old Black African man after cancer chemotherapy: a case report

Sebaceous carcinoma is a very rare malignant skin adnexal tumor that is occasionally aggressive. We have not seen a case of sebaceous carcinoma in our center in the last 10 years. It is extremely rare in Black...

The effect of Channa striata , Moringa oleifera , and Curcuma xanthorrhiza extract on accelerating recovery in a ventilated patient with hemorrhagic shock grade 3 due to prolonged retained placenta: a case report

Most of critically ventilated patients with severe hemorrhagic shock experience metabolic acidosis, hypoalbuminemia, electrolyte imbalance, and increased production of free radical. Channa striata has a high cont...

Infantile inflammatory bowel disease in three Syrian infants: a case series

Inflammatory bowel diseases, consisting of Crohn’s disease and ulcerative colitis, are chronic bowel relapsing inflammatory disorders. Inflammatory bowel diseases begin rarely in infants. Approximately 25% of ...

Two stents’ dislodgement in the left main coronary artery: a case report

Stent dislodgement is a life-threatening complication that can result in coronary artery embolization, stent thrombosis, acute myocardial infarction, and even death. Severely angulated, heavily calcified, and ...

An epidermal growth factor receptor compound mutation of L858R with S768I in advanced non-small-cell lung cancer: a case report

In the current treatment landscape for non-small cell lung cancers, epidermal growth factor receptor-tyrosine kinase inhibitors have emerged as a well-established treatment option for patients with advanced or...

Indoxacarb poisoning causing methemoglobinemia treated with parenteral vitamin C: a case report

This case study reports on a suicide attempt involving indoxacarb and vitamin C. Indoxacarb is a neurotoxic insecticide used in agriculture and as a flea controller in pets. Cotton, vegetables, and fruits are ...

Giant stone adhered in the vaginal cavity in a female patient with type 2 diabetes mellitus: a case report

Bladder lithiasis comprises 5% of urological lithiasis. Large bladder stones associated with vesicovaginal fistulas are rare, and the risk factors are not an isolated process. There are metabolic comorbidities...

Fulminant myocarditis during postoperative adjuvant chemotherapy for lung cancer with atezolizumab: a case report

Postoperative adjuvant systemic therapy with atezolizumab for lung cancer has been reported to be effective. Although myocarditis is a rare immune adverse event associated with atezolizumab, it can have a seri...

Bilateral vertebral artery injury leads to brain death following traumatic brain injury: a case report

Vertebral artery injury is a rare condition in trauma settings. In the advanced stages, it causes death.

Synovial sarcoma of the dorsal aspect of the hand: a case report

Synovial sarcoma is a rare soft tissue sarcoma, with incidences of 0.81/1,000,000 in children and 1.42/1,000,000 in adults. It is most commonly found in soft tissue and rarely in bone. It often has a slow grow...

Biomechanical gait analysis and rehabilitation in a traumatic hallux deficit patient: a case report

The hallux plays a crucial role in maintaining standing balance and facilitating forward and backward movements during gait.

Robotic resection for splenic artery aneurysm associated with neurofibromatosis type 1: a case report

Neurofibromatosis type 1 is an autosomal-dominant disease characterized by café-au-lait spots and neurofibromas, as well as various other symptoms in the bones, eyes, and nervous system. Due to its connection ...

Spontaneous knot formation complication of double J: two case reports

Use of ureteral stents has become an integral part of urological practice. However, it also brought with it many complications. Double J (DJ) stent knotting is a rare stent complication, and only a few cases h...

Nonketotic hyperglycemia hemichorea and hemiballismus: a case report

Diabetic striatopathy, also known as hyperglycemic hemichorea-hemiballismus, is a rare movement disorder associated with nonketotic hyperglycemia in patients with poorly controlled diabetes mellitus. The patho...

Segmental artery angioembolization as an efficient treatment modality for delayed hematuria with normal angiography: two case reports

Percutaneous nephrolithotomy is the most commonly used modality for the removal of kidney stones larger than 2 cm in size. Like other stone removal methods, percutaneous nephrolithotomy also has some complicat...

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What is a Medical Case Summary?

A medical case summary consists of the details that involves medical history that can be written in a narrative format . This encompasses all of the health providers that contains within the internal and external departments. This type of report will give you an alert whenever there are missing medical documents that may appear critical to every medical cases and provides an objective that assess if the standards set by the organization or institution have been met.

This case summary helps in determining the status of the type of health care a patient experiences together with the necessary supporting documents needed. Always make sure that the provided analysis reaches the scope and the summary is written concisely.

Content of Medical Case Summary

Biographical data of the patient
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You should have in mind that the information written in the case summary should be related and cross-referenced to the medical record of the patient.

Types of Medical Summary

Condition Specific Summary – these are often used for quality evaluations . This shows the conditions of the patient that displays the diagnosis and treatment. A condition specific summary is consist of the information about the medications, pathology review, laboratory results, etc.

Deep Document Reference – this is used for legal purposes in which conclusions are often sourced to the original document highlighting the missing records. This is often used in medical research.

Disability Specific Summary – this consists of the information regarding the disability, cause of disability, diagnosis, treatment history and treatment plans . These are often used in claim management and other medical-related actions.

Malpractice Incident Summary – this shows the cause of injury and its corresponding effect to the patient. They use a micro timeline followed by a condition summary so that further evaluations will be well-explained.

Narrative Summary – this explains all the components of the medical interventions including the cause, diagnosis, treatment, laboratory results, physician’s prescription, and more. This type of summary explains a story arranged in chronological order.

Condition Referenced Summary – this shows the reference view of the conditions of a particular patient.

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What is medical summarization process.

A medical summarization provides an avenue that lets you review for the purpose of legal processes. This is a summary taken from medical records that focuses on the complaint, observations, diagnosis, treatment plan, etc.

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A medical summarizer is responsible for providing a summary in all of the medical notes and letters. They make sure that they are all accurate and detailed. This type of medical records and patient’s notes are oftentimes transferred into a computer program.

What do you mean by summary of medical records?

It means that it has the complete medical details of the records that are essential for analysis.

A good medical summary has completed all the required information that is needed which includes the log of all medications and records of the past and present conditions of the patient. It is important because it can be used in analyzing medical data to be recorded at various facilities. This has to be written accurately and concisely.

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Published: 27 March 2024

Association of pharmacogenomic, clinical and behavioural factors with oral levothyroxine (LT-4) dose of hypothyroid patients in Sri Lanka: a matched case control study

S. S. Dalugodage 1 ,
Gayan Bowatte 2 ,
Charles Antonypillai 3 ,
S. Rajapakse 4 &
T. M. I. U. K. Tennakoon ORCID: orcid.org/0000-0001-9163-329X 1

BMC Medical Genomics volume 17 , Article number: 79 ( 2024 ) Cite this article

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Hypothyroidism is a common endocrine disorder that exerts a substantial influence on people all over the world. Levothyroxine (LT-4) is the drug of choice for the treatment of hypothyroidism and the starting oral dose is typically ranging from 1.5 to 1.7 µg/kg/day. The target is to achieve an optimum serum TSH level of 0.4-4.0 mIU/L; hence, the dose is titrated accordingly. Once the LT-4 dose is adjusted to obtain the target TSH level, it usually remains stable for a long period of time in most cases. However, some of the patients require frequent dose adjustments and some of them require unusually high doses. Therefore, the aim of this study is to determine the association of pharmacogenomic, clinical and behavioural factors with the oral levothyroxine (LT-4) dose requirement of hypothyroid patients in Sri Lanka.

This study will be conducted as a matched case-control study and will involve primary hypothyroid patients who visit the diabetes and endocrinology clinic at the National Hospital, Kandy, Sri Lanka. We will recruit a total of 292 cases and select 292 controls from the clinic who are matched in terms of age, sex and Body Mass Index (BMI). An interviewer-administered questionnaire will be used to collect data from the participants ( n = 584). Of the 584 patients, blood samples will be collected from a sub-sample ( n = 150) for DNA extraction. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) will be performed for single nucleotide polymorphisms (SNP) analysis.

Frequent dose adjustments of levothyroxine cause a serious economic burden to the healthcare system. By identifying the root causes of the variations in LT-4 dosage, a more comprehensive comprehension of hypothyroidism and its management can be attained in Sri Lanka. Furthermore, upon identification of a positive association/correlation between genetic polymorphisms and the LT-4 dose, SNP profiles can be used as a possible genetic marker for dose adjustment determination in future patients.

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Thyroxine (T4) and triiodothyronine (T3) are the major hormones secreted by the human thyroid gland and they are collectively called thyroid hormones [ 1 ]. Thyrotropin releasing hormone (TRH), which is secreted by the hypothalamus, regulates the synthesis and secretion of thyroid stimulating hormone (TSH) from the anterior pituitary and TSH regulates the synthesis and secretion of thyroid hormones from the thyroid gland [ 2 ]. The thyroid gland produces a high amount of T4; the inactive form, while producing a small amount of T3; the active form. In peripheral tissues, inactive T4 converts to active T3 by the enzymatic activity of deiodinases. There are several isoforms of deiodinase enzymes, such as D1, D2 and D3. D2 is the main enzyme in activating the pro-hormone T4 into T3. Low levels of free serum T3 and T4 will increase TSH secretion via the negative feedback system [ 3 ]. Deficiency of thyroid hormones in the body causes hypothyroidism [ 3 ].

Hypothyroidism is a common endocrine disorder worldwide [ 4 ]. However, data on the prevalence of primary hypothyroidism in Sri Lanka is scarce. The prevalence of autoimmune thyroiditis in Sri Lanka has been found to be 16–20% [ 5 ]. It is characterized by high levels of serum TSH (reference range of serum TSH is 0·4–4·0 mIU/L) and there are several categories of the disease. Primary hypothyroidism is caused by a pathology in the thyroid gland itself, which results in reduced secretion of thyroid hormone. This results in higher TSH and normal or low thyroid hormone levels. Secondary hypothyroidism is caused by pathologies in the hypothalamao-pituitary unit. This results in low TSH and low thyroxine levels. Out of these two types of hypothyroidism, primary hypothyroidism is the most common type [ 6 , 7 ]. Clinical (overt) hypothyroidism is manifested by an increased serum TSH level (> 10 mIU/L) and a reduced serum fT4 level (< 60 nmol/L), whereas sub-clinical hypothyroidism is manifested by a mildly increased serum TSH level (> 4 mIU/L) with a normal fT4 level [ 7 ]. However, the reference ranges may differ with the assay used, patient’s age, sex and ethnic group. Moreover, the upper limit of the adult serum TSH reference range typically increases with age [ 8 ].

Levothyroxine (LT-4) is the drug of choice for the treatment of hypothyroidism and it’s a synthetic T4 hormone [ 4 ]. The majority of the patients diagnosed with hypothyroidism require life-long treatment with levothyroxine [ 6 ]. Generally, patients with TSH levels > 10 mIU/L should start levothyroxine treatments [ 6 , 9 ]. The starting oral dose of LT-4 is typically ranging from 1.5 to 1.7 µg/kg/day (equivalent to approximately 100–125 mcg/day). However, older patients or patients with coronary artery disease may receive a lower starting dose of levothyroxine (25–50 µg/day) [ 6 , 10 ]. The LT-4 dose required by a patient can be determined by the total body weight, body mass index (BMI), lean body mass and ideal body weight using standard equations and the use of total body weight in this case may give the least accurate dose [ 11 , 12 ]. The target is to achieve an optimum serum TSH level of 0.4-4.0 mIU/L and hence, the dose is titrated accordingly [ 3 , 12 ]. LT-4 has a half-life of one week (about 7 days) and therefore serum TSH levels should be measured 4–6 weeks after starting the therapy or after a change in the dose. Once the target TSH level has been achieved, it can be reconfirmed after 3–6 months and then TSH monitoring should be done annually when stable [ 3 , 6 , 9 , 13 ].

Factors contributing to levothyroxine dose adjustments

Once the LT-4 dose is adjusted to obtain the target TSH level, it usually remains stable for a long period of time in most cases. However, around 10% of the patients, require dose adjustments during levothyroxine therapy and some of them will need unusually high doses of thyroid hormone replacement [ 14 ]. Factors including age, changes in body weight, coexisting medical conditions, concurrent medications, patient compliance, dietary habits, medication storage conditions and genetic factors may influence frequent dose changes of LT-4 [ 11 , 13 ].

Coexisting medical conditions

Levothyroxine absorption is known to be affected by the gastric pH and hence, concomitant gastrointestinal (GI) diseases that impair gastric acid secretion or cause malabsorption may contribute to higher dose requirements [ 15 , 16 ]. GI conditions such as Helicobacter pylori infection (reduce gastric acid secretion and produce ammonia), atrophic gastritis, coeliac disease, lactose intolerance, gastric bypass, inflammatory bowel disease and intestinal giardiasis are found to be associated with higher dose requirements [ 17 , 18 ]. Patients with nephrotic syndrome may also require higher doses due to the urinary loss of thyroxine-binding globulin with thyroxine [ 19 ].

Concurrent medications

Some other medications, when taken along with LT-4 can lead to several drug-drug interactions and alter the LT-4 replacement dose requirements in patients. Proton-pump inhibitors (PPIs) including omeprazole, esomeprazole, lansoprazole etc., antacids and Histamine (H2)-receptor blockers reduce the gastric acid secretion and hence interfere with LT-4 absorption [ 14 , 20 ]. In addition to that, ion exchange resins, bile acid sequestrants (cholestyramine, colestipol), sevelamer, laxatives, orlistat and sucralfate are known to reduce the absorption of LT-4 [ 20 , 21 , 22 ]. Moreover, supplements such as calcium and iron may form insoluble complexes with LT-4 inside the intestine and reduce the absorption [ 23 ]. Thus, concurrent use of these medicines may increase the dose requirements of LT-4 [ 14 , 23 ]. Carbamazepine, hydantoins, phenobarbital and rifampicin may increase the hepatic metabolism of LT-4 and increase the dose requirement. Medicines such as amiodarone, iodide-including and iodine-containing radiographic contrast agents, methimazole, propylthiouracil and lithium may reduce thyroxine secretion and hence increase the dose requirement. Furthermore, oestrogen therapy, clofibrate, heroin/methadone, mitotane and tamoxifen may increase serum thyroxine binding globulin concentration and thus, they all increase the dose requirement of LT-4 [ 12 , 14 ].

Patient compliance

Typically, in Sri Lankan health settings hypothyroid patients are advised to take their levothyroxine tablets with a full glass of water every morning, quickly after waking up. They are advised not to take any foods or beverages for about 30–60 min after taking LT-4. If the patient is taking medicines for another disease condition, he/she is informed to separate LT-4 and those medications by 2–4 h. Furthermore, patients are encouraged to take the same brand name product of LT-4 [ 24 , 25 ]. Poor compliance with the therapy is a major factor to consider when finding causes for frequent dose adjustments or higher dose requirements.

A recent study has concluded that taking LT-4 half an hour before breakfast, an hour before the main meal of the day and at bedtime (minimally 2 h after dinner) are equally effective and can be used to enhance patient compliance [ 26 ].

Dietary habits

Frequent consumption (more than twice a week) of soy-based products (soybeans, soy milk, tofu), foods high in fiber (bran flakes, fiber drinks, broccoli, nuts, whole grains), foods high in iodine (cod, plain yogurt), grapefruit/grapefruit juice and coffee/tea with LT-4 may increase the serum TSH levels and may increase LT-4 dose requirements [ 20 , 23 ].

Medication storage conditions

According to the guidelines, levothyroxine should be stored at 20–25 °C (68–77 °F) and protected from light and moisture [ 25 ]. A recent study has proven that improper storage conditions can increase serum TSH levels and thereby increase the dose requirements [ 27 ].

Genetic variations

Genetic polymorphisms are known to be responsible for most of the common genetic variations among humans [ 28 ]. Researchers suggest that the wide variability of LT-4 doses required by the patients may have an association with SNPs of TSHRs, THRs, thyroid hormone transporters and deiodinase enzymes [ 14 , 28 , 29 ]. A study conducted in 2013 has concluded that single nucleotide polymorphisms (SNPs) rs225011, rs7140952, rs225012 and rs2839858 in DIO2 gene are not correlated with the replacement doses of the LT-4 whereas, rs7140952 polymorphism was found to be associated with components of metabolic syndrome including blood pressure and central obesity. Moreover, the researchers have stated that this association might be population dependant [ 11 ]. In another study, an association between TSHR gene SNP (rs2268458), which is in intron 1, and a higher incidence of Graves’ disease has been found [ 30 ]. Furthermore, the CC genotype of TSHR SNP (rs2239610) has been found to be associated with higher serum concentrations of fT4 [ 31 ]. Torlontano et al. have found a positive association between DIO2 polymorphism (D2 Thr92Ala) and the required dose of L-T4 in thyroidectomised patients [ 32 ].

According to the best of our knowledge, no studies have been conducted to explore the association between above mentioned factors and LT-4 dose adjustments in Sri Lankan population. Therefore, we intend to investigate the possible association of LT-4 dose requirement in hypothyroid patients and pharmacogenomic, clinical and behavioural factors.

Research objectives

The goal of this study is to determine the association of pharmacogenomic, clinical and behavioural factors with oral levothyroxine (LT-4) replacement dose of hypothyroid patients in Sri Lanka. Specifically, we are going to determine;

The association of factors including coexisting medical conditions, concurrent medications, patient compliance, dietary habits and medication storage conditions with the LT-4 replacement dose.

The association between genetic polymorphisms in the THR gene, TSHR gene and DIO2 gene and the LT-4 replacement dose.

Methods/design

Study design.

A matched case-control study will be conducted, with the selection of hypothyroid patients who are currently receiving LT-4 treatment as study participants.

Definition of the cases

Patients visiting the Kandy National Hospital’s diabetes and endocrinology clinic with a LT-4 replacement dose > 1.7 µg/kg/day.

Definition of controls

Patients visiting the Kandy National Hospital’s diabetes and endocrinology clinic with a LT-4 replacement dose 1.7 µg/kg/day or less (normal doses).

These patients will be identified as hypothyroid patients by the investigation of a physician and laboratory tests (TSH and fT4). Of the pool of hypothyroid patients with normal doses (1.7 µg/kg/day or less), the controls will be selected using convenience sampling. Age, gender, and BMI will be matched in cases and controls. One control per case will be selected.

Study setting and population

Primary hypothyroid patients who visit the diabetes and endocrinology clinic at the National Hospital, Kandy, Sri Lanka will be recruited ( n = 584). Sample size was calculated using following formula [ 33 ].

p 0 = Proportion of controls with exposure (Nair S, et al.) [ 34 ].

p 1 = Proportion of cases with exposure (Nair S, et al.) [ 34 ].

z 1−α/2 = Standard normal variate for level of significance.

z 1−β = Standard normal variate for power.

q 0 = 1-p 0 .

q 1 = 1-p 1 .

We will recruit a total of 292 cases and select 292 controls from the clinic who are matched in terms of age, sex and BMI.

Inclusion criteria: cases

Patients with primary hypothyroidism who require higher doses of thyroxine (more than 1.7 µg/kg/day) for the preceding 3 months.

Age 18 years to 65 years.

Patients who have given consent.

Inclusion criteria: controls

Patients with primary hypothyroidism requiring thyroxine normal doses (1.7 µg/kg/d or less) for the preceding 3 months with normal TSH.

Exclusion criteria: Cases and controls .

Patients who are pregnant or planning for pregnancy within 6 months.

Patients with secondary hypothyroidism.

Patients who are newly diagnosed with hypothyroidism (< 1 year).

Patients with a history of differentiated thyroid malignancies.

Patients who are being treated for psychiatric illness.

Patients with established atherosclerotic cardiovascular disease or arrhythmias.

Sample and data collection

Cases and controls will be selected using convenience sampling. Informed written consent will be obtained from all the participants. A researcher-administered questionnaire will be administered to obtain data on age, gender, ethnicity, year of diagnosis, aetiology of hypothyroidism, the current dose of thyroxine and brand, last TSH within 3 months, time of thyroxine ingestion and time to next meal or drink, dietary habits, number of days missing the tablets per month, whether the patient is storing the tablets correctly, interfering drugs and the other drugs that the patient is on and the other medical conditions that the patient is having. The body weight and height of the patient will be measured using the same scale for every patient, and BMI will be calculated.

Blood sample collection

A sub-sample of cases ( n = 75) and their respective controls ( n = 75) will be recruited randomly from the initial sample of 584 patients for SNP analysis due to the limited availability of resources. Blood samples will be collected from those patients ( n = 150) and will be used for SNP analysis by PCR/RFLP method.

The current study will investigate the possible association between LT-4 doses in hypothyroid patients and THRα rs939348 SNP, TSHR rs2268458 SNP, TSHR rs2239610 SNP and rs225011, rs7140952, rs225012 and rs2839858 SNP’s in DIO2 gene. The PCR primers, restriction enzymes and the expected sizes of the amplified and digested fragments of the examined SNPs are shown in Tables 1 and 2 .

The PCR will be carried out using a blood PCR Kit. The genomic DNA will be amplified using a PCR programme that is suitable for the above mentioned SNPs. Tables 1 and 2 summarizes restriction enzymes and restricted fragments for all SNPs. The PCR products and digested fragments will be detected using electrophoresis on 2% agarose.

Gene sequencing to identify new SNP variants

Direct Sanger sequencing will be done to identify new variants of DIO2 genes in patients who have been on thyroxine more than 2.5 micrograms/kg/day dose for the last 3 months period. The obtained gene sequences will be compared with the reference sequence from the National Centre for Biotechnology Information (NCBI).

Statistical analysis

Before data entry, all data forms and questionnaires will undergo a thorough check for errors, and necessary corrections will be made. The data will be entered using a data entry program equipped with built-in range and consistency checks. An analysis of frequency distributions will be conducted to identify any outliers.

Data will be analysed using Stata software (Stata Corp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC.). The mean and standard error will be presented for data that follows a normal distribution. Conversely, non-normal distributed data will be expressed as medians with interquartile ranges. Descriptive analysis of all variables and comparisons between case and control groups will be presented. T-tests will be used for continuous variables, and Chi-square tests for discrete variables. Logistic regression and multinomial logistic regressions will be used to investigate the associations between predictor variables, such as coexisting medical conditions, concurrent medications, patient compliance, dietary habits and medication storage conditions with the LT-4 replacement dose. Potential confounders will be identified using Direct Acyclic Graphs (DAG) and existing literature. The identified confounders will be adjusted in the multivariate models. All the results will be presented before and after adjustment for confounding variables. The genotype distributions of SNPs will be analysed in agreement with the Hardy-Weinberg equilibrium. The association between genetic polymorphisms and the LT-4 replacement dose will be analysed using logistic and multinomial logistic regression models adjusting for potential confounders.

In gene sequencing, the obtained gene sequences will be compared with the reference sequence from the National Centre for Biotechnology Information (NCBI). The sequences will be analysed using BioEdit software.

Hypothyroidism is a common endocrine disorder worldwide [ 4 ]. Females are more prone to the disease than males and the prevalence increases with age [ 3 , 8 ]. If hypothyroidism is left untreated, it may cause severe adverse effects and ultimately death [ 8 ]. Hypothyroidism can be diagnosed and monitored by evaluating clinical symptoms and thyroid function testing; mainly serum TSH level and serum fT4 level [ 9 ]. Hypothyroidism shows symptoms such as mild to moderate weight gain, hyperlipidaemia, skin manifestations/dry skin, fatigue, constipation, coarseness or loss of hair, bradycardia, hypothermia, myalgia, depression, menstrual irregularities and lack of concentration [ 3 , 11 ]. However, clinical manifestations of hypothyroidism may range from life threatening to no signs or symptoms [ 8 ].

The common causes for primary hypothyroidism are autoimmune disease of the thyroid gland/Hashimoto thyroiditis (major cause), thyroid surgery/surgical removal of the thyroid gland, thyroid gland ablation with radioiodine or external radiation when there is an iodine sufficiency [ 6 , 7 ]. There are several other causes for primary hypothyroidism and they can be listed as antithyroid medications (propylthiuracil), thyroid gland tumors, biosynthetic defects in iodine organification, iodine deficiency or excess (Wolff-Chaikoff effect) and some medications such as amiodarone (contains iodine), lithium, tyrosine kinase inhibitors and cytokines (interferon-γ and interleukin-2) [ 3 , 6 ].

Generally, hypothyroidism can be adequately treated with a consistent daily dose of oral levothyroxine. However, around 10% of the patients, require frequent dose adjustments during levothyroxine therapy and some of them will need unusually high doses of thyroid hormone replacement [ 14 ]. Patients who undergo multiple levothyroxine dose adjustments consume more healthcare resources and hence, these frequent dose adjustments cause a serious economic burden to the healthcare system [ 36 ]. Although many studies have been conducted to explore the association of levothyroxine dose adjustment with demographic factors and genetic factors, there are no studies available on the Sri Lankan population. Especially, genetic factors may differ from one population to another. Authors of previous studies that have been conducted to explore the possible associations between SNPs and LT-4 replacement dose, have declared that their results might be population dependant [ 11 , 32 ]. Therefore, it is important to see the applicability of these already-described factors to our population.

Understanding underlying causes for variations in LT-4 dose will lead to a better understanding of hypothyroidism and its management in Sri Lanka and similar low-resource settings. Furthermore, if a positive association/correlation is found between genetic polymorphisms and the LT-4 dose, SNP profiles can be used as a possible genetic marker for dose adjustment determination in future patients. Moreover, the results of this study will guide to launch of further research studies in this field.

A potential limitation of this study is that our sample for the SNP analysis is small due to the limited availability of resources. We expect this study will help to understand the causes of frequent dose adjustments in LT-4 treatment.

Data availability

Not applicable.

Abbreviations

Body mass index

Deiodinases 1, 2 and 3

Deiodinases 2 gene

Free thyroxine

Gastrointestinal

Levothyroxine

National Centre for Biotechnology Information

Polymerase Chain Reaction

Proton-pump inhibitor

Single nucleotide polymorphism

Statistical analysis for the social sciences

Thyroid hormone receptor

Thyroid stimulating hormone

Thyroid stimulating hormone receptors

Thyrotropin releasing hormone

Triiodothyronine

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Acknowledgements

This study is funded by the University of Peradeniya research grant URG/2022/15/AHS .

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Authors and affiliations.

Department of Pharmacy, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya, Sri Lanka

S. S. Dalugodage & T. M. I. U. K. Tennakoon

Department of Basic Sciences, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya, Sri Lanka

Gayan Bowatte

National Hospital, Kandy, Sri Lanka

Charles Antonypillai

Department of Molecular Biology and Biotechnology, Faculty of Science, University of Peradeniya, Peradeniya, Sri Lanka

S. Rajapakse

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Contributions

All authors contributed to the design of the study. SD drafted the manuscript and all authors IT, GB, CA and SR commented on it. All authors read and approved the final manuscript.

Corresponding author

Correspondence to T. M. I. U. K. Tennakoon .

Ethics declarations

Ethics approval and consent to participate.

Ethics approval has already been obtained from the ethics review committee of the Faculty of Allied Health Sciences, University of Peradeniya (certificate no.: AHS/ERC/2022/126). Furthermore, written approval from the hospital Director has been obtained from the national hospital, Kandy. Informed written consent will be obtained from all the participants before recruiting to the study.

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Published on 1.4.2024 in Vol 10 (2024)

Using Project Extension for Community Healthcare Outcomes to Enhance Substance Use Disorder Care in Primary Care: Mixed Methods Study

Authors of this article:

Original Paper

MacKenzie Koester, MPH ;
Rosemary Motz, MPH, MA, RDN ;
Ariel Porto, MPH ;
Nikita Reyes Nieves, MPH ;
Karen Ashley, EdD

Weitzman Institute, Moses Weitzman Health System, Washington, DC, United States

Corresponding Author:

MacKenzie Koester, MPH

Weitzman Institute

Moses Weitzman Health System

1575 I Street Northwest

Washington, DC, 20005

United States

Phone: 1 8603476971

Email: [email protected]

Background: Substance use and overdose deaths make up a substantial portion of injury-related deaths in the United States, with the state of Ohio leading the nation in rates of diagnosed substance use disorder (SUD). Ohio’s growing epidemic has indicated a need to improve SUD care in a primary care setting through the engagement of multidisciplinary providers and the use of a comprehensive approach to care.

Objective: The purpose of this study was to assess the ability of the Weitzman Extension for Community Healthcare Outcomes (ECHO): Comprehensive Substance Use Disorder Care program to both address and meet 7 series learning objectives and address substances by analyzing (1) the frequency of exposure to the learning objective topics and substance types during case discussions and (2) participants’ change in knowledge, self-efficacy, attitudes, and skills related to the treatment of SUDs pre- to postseries. The 7 series learning objective themes included harm reduction, team-based care, behavioral techniques, medication-assisted treatment, trauma-informed care, co-occurring conditions, and social determinants of health.

Methods: We used a mixed methods approach using a conceptual content analysis based on series learning objectives and substances and a 2-tailed paired-samples t test of participants’ self-reported learner outcomes. The content analysis gauged the frequency and dose of learning objective themes and illicit and nonillicit substances mentioned in participant case presentations and discussions, and the paired-samples t test compared participants’ knowledge, self-efficacy, attitudes, and skills associated with learning objectives and medication management of substances from pre- to postseries.

Results: The results of the content analysis indicated that 3 learning objective themes—team-based care, harm reduction, and social determinants of health—resulted in the highest frequencies and dose, appearing in 100% (n=22) of case presentations and discussions. Alcohol had the highest frequency and dose among the illicit and nonillicit substances, appearing in 81% (n=18) of case presentations and discussions. The results of the paired-samples t test indicated statistically significant increases in knowledge domain statements related to polysubstance use ( P =.02), understanding the approach other disciplines use in SUD care ( P =.02), and medication management strategies for nicotine ( P =.03) and opioid use disorder ( P =.003). Statistically significant increases were observed for 2 self-efficacy domain statements regarding medication management for nicotine ( P =.002) and alcohol use disorder ( P =.02). Further, 1 statistically significant increase in the skill domain was observed regarding using the stages of change theory in interventions ( P =.03).

Conclusions: These findings indicate that the ECHO program’s content aligned with its stated learning objectives; met its learning objectives for the 3 themes where significant improvements were measured; and met its intent to address multiple substances in case presentations and discussions. These results demonstrate that Project ECHO is a potential tool to educate multidisciplinary providers in a comprehensive approach to SUD care.

Introduction

In the United States, overdose deaths continue to be a major cause of injury-related deaths. Since the onset of the COVID-19 pandemic, numbers have only accelerated, and the state of Ohio has led the nation in high substance use disorder (SUD) rates, including drug use and prescription drug use. The Centers for Disease Control and Prevention ranks the state among the top 5 across the United States with the highest rates of opioid overdose deaths [ 1 ]. While research has shown an increase in the number of people enrolled in substance use treatment in Ohio between 2015 and 2019 there was still a notable high increase in the annual average prevalence of past-year illicit drug use disorder in Ohio (3.6%) compared to the regional average (3%) and the national average (2.9%) [ 2 ]. In addition, past-month alcohol use disorder (9.3%), cannabis use disorder (5.8%), and tobacco use disorder (35.2%) were higher than the national average among young adults aged 18-25 years [ 2 ]. Ohio’s growing epidemic has highlighted the need to improve SUD care in a primary care setting by training providers to better address differences in care and social determinants of health through the use of behavioral techniques, harm-reduction philosophy of care, medication management, and a team-based care approach.

Weitzman Extension for Community Healthcare Outcomes: Comprehensive Substance Use Disorder Care Program

Beginning in 2021, Buckeye Health Plan and Ohio University Heritage College of Osteopathic Medicine have partnered with the Weitzman Institute (WI), a national primary care research, policy, and education institute, to provide targeted support and education to Ohio primary care medical and behavioral health providers working with underserved patients, especially those in the rural, southeastern Appalachian region, using the evidence-based Project Extension for Community Healthcare Outcomes (ECHO) learning model. Project ECHO uses frequent videoconference sessions to connect a target audience of learners with subject matter experts for didactic and case-based instruction and engaged discussion [ 3 ]. Through regular attendance at these sessions, Project ECHO aims to equip learners with the knowledge, confidence, and skills to better manage complex cases.

WI has over 11 years of experience in developing and delivering Project ECHO programs to meet the needs of providers working in resource-limited settings. As an early adopter of the model in 2012, Weitzman ECHO programs have been offered in 22 topic areas to over 8000 health care professionals across all 50 states, Washington D.C., and Puerto Rico. Working in collaboration, Buckeye Health Plan and Ohio University aimed to leverage this expertise and offer multiple Project ECHO programs each year for providers in topics of the greatest need and interest.

As described, one of Ohio’s most dire population health needs is to improve outcomes for patients experiencing addiction. Thus, SUD was selected as the second ECHO program developed through this partnership. More specifically, opioids are a heightened concern throughout both Ohio and the United States, and the opioid epidemic has spurred significant funding allocations, such as the Biden Administration’s US $1.5 billion award to states and territories to end the epidemic [ 4 ]. However, there are many additional substances of concern, both illicit and nonillicit, such as alcohol, tobacco, cannabis, methamphetamine, and cocaine [ 5 ], which may receive less attention given the directed funding for opioids. For this reason, it was decided that the ECHO would address not only opioids, or any one substance, but rather be designed to provide techniques to help providers address SUD overall through a comprehensive, team-based lens and a harm reduction philosophy of care. Reflecting this broad topical approach, the program was titled the Weitzman ECHO: Comprehensive Substance Use Disorder Care (CSUDC ECHO) program.

CSUDC ECHO consisted of 24 twice-monthly sessions held between July 2021 and July 2022. Each 1-hour session included a 20- to 25-minute didactic presentation followed by 1 patient case submitted by a participant before the session and discussed live for the remaining 35-40 minutes. Textbox 1 outlines the didactic presentation topics for each session. A multidisciplinary core faculty facilitated each session and was comprised of 1 physician with dual board certification in family medicine and addiction medicine and experienced in treating SUDs at federally qualified health centers; 1 nurse practitioner who developed and leads a federally qualified health center medication-assisted treatment (MAT) program; 1 supervisory licensed counselor; and 1 population health expert. Together, the faculty built a 12-month curriculum covering diverse topics such as medication management, team-based care, trauma-informed care, stages of change and motivational interviewing, polysubstance use and co-occurring conditions, and coordinating levels of care.

Session and didactic topic

Philosophy of care (no case presentation).
Harm reduction strategies.
Principals of medication management.
Team-based care: care provision partners.
Trauma-informed care: an overview.
Motivational interviewing.
Stages of change for addiction.
Assessing stages of change and stage-based interventions.
Medications for opioid use disorder basics.
Behavioral health and primary care coordination.
Transitions of care.
Polysubstance use.
Social determinants of health including barriers or challenges (no case presentation).
Adverse childhood experiences.
Legal factors and access.
Mental health crisis and coordination of care.
Medication-assisted treatment for alcohol and tobacco use disorders.
Self-determination and strength-based approaches.
Contingency management for substance use disorder.
HIV and hepatitis C virus in patients with substance use disorder.
Screening, brief intervention and referral to treatment into primary care.
Stimulant use disorder treatment and medication management.
Co-occurring mental health substance use disorder.
Tobacco cessation for polysubstance patients.

Participants were recruited by email blasts targeted to each partner’s network of Ohio primary care providers and other members of the care team. A total of 109 participants attended at least one session, 16 participants attended between 7 and 11 sessions, and 23 participants attended over 12 (half) of the sessions. On average, there were 32 attendees at each session. Continuing education credits were offered to medical providers, behavioral health providers, and nurses.

Purpose of Study

The purpose of this study was to assess the ability of CSUDC ECHO to both address and meet 7 learning objectives ( Textbox 2 ) and address multiple substances by analyzing (1) the frequency of exposure to the learning objective topics and substance types during case discussions and (2) participants’ knowledge, self-efficacy, skills, and attitudes related to the treatment of SUDs pre- to postprogram.

Project a harm reduction philosophy of care into your treatment of patients experiencing substance use disorders and explain this concept to peers.
Use the care team more effectively to improve the management of patients experiencing substance use disorders.
Use motivational interviewing and other behavioral techniques to improve patient outcomes related to substance use disorders.
Better differentiate and implement medication management strategies for patients experiencing substance use disorders.
Illustrate trauma-informed practices in the screening, assessment, and treatment of patients experiencing substance use disorders.
Describe and manage common co-occurring conditions and polysubstance use more effectively in patients experiencing substance use disorders.
Distinguish and address factors related to social determinants of health faced by specific populations experiencing substance use disorders.

Study Design and Data Collection

This study used a mixed methods design, using a conceptual content analysis [ 6 ] analyzing ECHO participant-led case presentations, as well as a 2-tailed paired-samples t test of participant self-reported learner outcomes. All ECHO attendees who registered and attended the Project ECHO CSUDC sessions are included in the deductive content analysis. All ECHO attendees who registered before and through the first session of the series were invited to complete a preseries survey (n=106) via Qualtrics survey software (Qualtrics). The preseries survey remained open for 3 weeks from June 25, 2021, to July 18, 2021. A total of 79 responses were received (n=79) for a response rate of 75%. Upon completion of the ECHO series, active attendees (ie, those that were still active at the conclusion of the series and did not officially drop from the series, as well as those who enrolled throughout the series) were invited to complete a postseries survey via Qualtrics Survey Software (n=90). The postseries survey remained open for 4 weeks from July 7, 2022, to August 2, 2022. A total of 25 responses were received (n=25) for a response rate of 28%. A total of 16 consented participants completed both the preseries and postseries surveys (n=16) and are included in the paired-samples t tests statistical analysis.

Ethical Considerations

This study was approved by the Community Health Center, Inc, Institutional Review Board (IRB; 1190) on January 6, 2022. Informed consent was accounted for by the authors through the administration of a consent form on the postseries survey gathering participant consent to use their deidentified survey data for the paired-samples t test analysis. The deductive content analysis was considered a secondary analysis and was given exempt status. All data used in this study were deidentified, accounting for privacy and confidentially. No compensation for participation in this study was deemed necessary by the IRB.

Survey Tools

The preseries and postseries surveys were internally created and based on the Consolidated Framework for Implementation Research (CFIR) [ 7 ] and Moore’s Model of Outcomes Assessment Framework [ 8 ]. The specific CFIR domains assessed for include intervention characteristics, outer setting, inner setting, characteristics of individuals, and process [ 7 ]. Additionally, the levels of Moore’s Model of Outcomes Assessment Framework assessed for include level 2 (satisfaction), level 3a (declarative knowledge), level 3b (procedural knowledge), level 4 (competence), level 5 (performance), and level 6 (patient health) [ 8 ]. The surveys assessed changes in participants’ self-reported knowledge, attitudes, self-efficacy, and skills through statements centered on the series’ learning objectives. The preseries survey also collected participant characteristics including provider type and years of experience working with patients diagnosed with SUDs, as well as team-based care practices. Additionally, the postseries survey collected information on engagement and practice changes. The preseries survey instrument is presented in Multimedia Appendix 1 and the postseries survey instrument is presented in Multimedia Appendix 2 .

While the preseries survey and postseries survey tools were based on CFIR [ 7 ] and Moore’s Model of Outcomes Assessment Framework [ 8 ], both surveys were internally designed. The internal research and evaluation and CSUDC ECHO programmatic teams created the survey tools through several iterations of the internal review, which also consisted of selecting the appropriate domain (ie, knowledge, attitudes, self-efficacy, and skills) to assess each series’ learning objective. Each domain used a 5-point Likert scale to assess responses. The surveys were then presented to the CSUDC ECHO series stakeholders and faculty for review and approval before administering the surveys to the ECHO attendees. See Multimedia Appendices 1 and 2 for the domain placement of learning objectives and the 5-point Likert scales.

Conceptual Content Analysis

To further evaluate Weitzman ECHO CSUDC aims, researchers conducted a conceptual content analysis [ 6 ] using a set of a priori themes extracted from the series’ learning objectives. Series’ learning objectives are detailed in Textbox 2 . To establish a priori themes, researchers met before the launch of the ECHO to examine the series’ 7 learning objectives and extracted 7 themes for the content analysis. The themes were: harm reduction, team-based care, behavioral techniques, MAT, trauma-informed care, co-occurring conditions, and social determinants of health. To assess the frequency to which multiple substances were discussed, the themes also included 5 illicit and nonillicit substances of concern: alcohol, stimulants, opioids, cannabis, tobacco, or nicotine, plus polysubstance use when any 2 or more of these substances were identified. A conceptual analysis approach was used to gauge the dose and frequency of all learning objective themes and selected illicit and nonillicit substances. The content analysis aimed to confirm the discussion of the series’ learning objectives during case presentations and to determine to what extent multiple substances were able to be addressed.

Researchers evaluated all 22 participant-led ECHO case presentations and discussions for the presence of the selected themes in the prepared participant cases, faculty recommendations, and participant recommendations. Case presentations and discussions consisted of participants independently preparing a patient case to present and receive participant and faculty guidance for a patient treatment plan. Case presentations were recorded and transcribed using Zoom videoconferencing software (Zoom Video Communications, Inc). The transcriptions were then used for the conceptual content analysis.

To ensure coding accuracy, 4 researchers independently coded 27% (n=6) of the case presentations and met to reconcile discrepancies and better establish coding parameters. After reconciling discrepancies, 1 researcher coded the remaining 16 case presentations and discussion transcripts. The content analysis themes and descriptions are presented in Table 1 .

Paired-Samples t Test

To determine if Project ECHO CSUDC affected participant learner outcomes, researchers calculated mean scores reported on a Likert scale of 1 to 5 and conducted a paired-samples t test to compare pre- and postseries scores at a .05 significance level. The surveys consisted of matching statements assessing knowledge, self-efficacy, attitudes, and skills associated with the series’ learning objectives. The data were assessed for normality and homogeneity of variance and the assumptions were met. The data analysis was conducted using SPSS Statistics for Windows (version 26.0; IBM Corp).

Participant Characteristics

CSUDC ECHO participants were asked to report their role type on the preseries survey. Of the participants that responded to the survey items (n=79), a majority were other care team members (n = 32; 41%) followed by behavioral health providers (n = 30; 38%) and medical providers (n = 16; 21%). Additionally, participants were asked to indicate their years of experience working with SUDs. Most participants had between 1 and 5 years of experience (n=23; 29%) followed by 6-10 years (n=15; 19%), 11-20 years (n=14; 18%), less than 1 year (n=13; 16%), 7 participants indicated they do not work directly with patients (n=7; 9%), 21-30 years (n=4; 5%), 31-40 years (n=2; 3%), and more than 40 years of experience (n=1; 1%). Full participant characteristics of the entire CSUDC ECHO attendees, excluding the paired-samples t test sample, the paired-samples t test sample only, and all combined CSUDC ECHO attendees are provided in Table 2 .

The attendance data of participants included in the paired-samples t test analysis were analyzed. Further, 6 (n=6; 38%) of the paired-samples t test participants attended 1% (n=1) to 25% (n=6) of the 24 CSUDC ECHO sessions, 3 (n = 3; 19%) attended 26% (n=7) to 49% (n=11) of the sessions, 4 (n = 4; 25%) attended 50% (n=12) to 75% (n=18) of the sessions, and 3 (n = 3; 19%) attended 76% (n=19) to 100% (n=24) of the sessions.

a ECHO: Extension for Community Healthcare Outcomes.

b CSUDC: Comprehensive Substance Use Disorder Care.

c SUD: substance use disorder.

The conceptual content analysis indicated that all of the a priori themes relating to the learning objectives resulted in high frequencies and doses, appearing in a majority of case presentations and discussions. Further, 3 themes appeared in 100% (n = 22) of case presentations and discussions, including team-based care at a frequency of 156, followed by harm reduction at a frequency of 152, and social determinants of health at a frequency of 135. In total, 4 themes appeared in less than 100% (n=22) of case presentations and discussions, but above 81% (n=18), including co-occurring conditions with a frequency of 118 and appearing in 95% (n = 21) of case presentations and discussions, followed by behavioral techniques at a frequency of 108 and appearing in 91% (n = 20) of case presentations and discussions, MAT at a frequency of 89 and appearing in 86% (n = 19) of case presentations and discussions, and trauma-informed care at a frequency of 79 and appearing in 82% (n=18) case presentations and discussions. Additionally, multiple substances were represented but at differing frequencies. The substance that resulted in the highest frequency and dose was alcohol at a frequency of 64 and appeared in 81% (n = 18) of case presentations and discussions, followed by stimulants at a frequency of 55 and 77% (n=17) of case presentations and discussions, opioids at a frequency of 49 and 59% (n = 13) of case presentations and discussions. Cannabis resulted with a frequency of 38 but appeared in 64% (n = 14) of case presentations and discussions. Finally, tobacco and nicotine resulted in the lowest frequency at 11 and dose appearing in 27% (n = 6) of case presentations and discussions. When evaluating polysubstance use, which was limited to the use of two or more of the listed substances, we found a dose of 95% (n = 21) of case presentations and discussions. The frequency of polysubstance use was not included in the conceptual content analysis since it was not a learning objective theme and the emphasis of the conceptual content analysis was focused on the specific illicit and nonillicit substance types. The results of the conceptual content analysis are presented in Table 3 .

a MAT: medication-assisted treatment.

b —: not available.

In total, 4 knowledge domain statements resulted in statistically significant increases: understanding polysubstance use in patients experiencing SUD ( P =.02), understanding the approach colleagues in other disciplines use to address SUD ( P =.02), knowledge of medication management strategies for nicotine use disorder ( P =.03), and knowledge of medication management strategies for opioid use disorder (OUD; P =.003). Additionally, all knowledge domain statements resulted in an increased change in mean score from preseries to postseries. The results of the knowledge domain preseries and postseries scores are presented in Table 4 .

No attitudes domain statements resulted as statistically significant. All attitudes domain statements resulted in an increased change in mean score from preseries to postseries except the statement about a treatment plan for a patient experiencing an illicit SUD only being successful if abstinence is maintained, which resulted in a negative change in mean score. The negative change in mean score from preseries to postseries was the appropriate direction of change for alignment with promoting a harm reduction philosophy. The results of the attitudes domain preseries and postseries scores are presented in Table 5 .

Self-Efficacy

In total, 2 self-efficacy statements resulted in statistically significant increases: choosing a medication management strategy for nicotine use disorder ( P =.002) and alcohol use disorder ( P =.02). Additionally, all self-efficacy domain statements resulted in an increased change in mean score from preseries to postseries. The results of the self-efficacy domain preseries and postseries scores are presented in Table 6 .

a SMART: specific, measurable, achievable, relevant, timely.

In total, 1 skill domain statement resulted in a statistically significant increase: using the stages of change theory to provide stage-based interventions to patients experiencing SUDs ( P =.03). Additionally, all skill domain statements resulted in an increased change in mean score from preseries to postseries. The results of the skill domain preseries and postseries scores are presented in Table 7 .

a IOP: intensive outpatient.

Principal Findings

Ohio’s annual average prevalence of tobacco use, heroin use, use of prescription pain relievers, OUDs, illicit drug use disorder, and SUD have been higher compared to both regional and national averages [ 2 ]. Considering the need to address this public health concern, CSUDC ECHO was implemented to train Ohio providers and care team members in substance use care. CSUDC ECHO enhanced the Project ECHO work in this field by focusing content and learning objectives on a comprehensive, team-based lens and a harm reduction philosophy of care to address multiple illicit and nonillicit substances including opioids, alcohol, nicotine, cannabis, and stimulants. To assess the ability of the CSUDC ECHO program to meet its 7 program learning objectives ( Textbox 2 ) and address multiple substances, this study analyzed (1) the frequency of exposure to learning objective themes and substance types during case presentations and discussions and (2) participating providers’ change in knowledge, attitudes, self-efficacy, and skills related to the treatment of SUDs.

Study results demonstrate that all 7 learning objectives were frequently addressed in the content of case presentations and discussions throughout the program, with team-based care being the most frequently mentioned, 3 objectives appearing in 100% (n=22) of case discussions (eg, team-based care, harm reduction, and co-occurring conditions), and all 7 objectives appearing in >81% (n=18) of all cases discussed. This may have resulted in the learner outcome improvement pre- to postprogram for multiple learner domains (eg, knowledge, self-efficacy, and skill) for the following themes: team-based care, MAT, polysubstance use, and behavioral techniques. No pattern emerged among the participants included in the paired-samples t test analysis exposure to didactic topics and changes in learner outcomes.

Alcohol, stimulants, opioids, cannabis, and nicotine were addressed in the content of case presentations and discussions throughout CSUDC ECHO with alcohol being the most frequently mentioned and most common substance appearing in cases, 4 substances appearing in >59% (n=13) of case discussions (eg, alcohol, stimulants, opioid, and cannabis), and all coded substances appearing in at least a quarter of cases. The dialogue about these substances during case discussions likely resulted in improvements to the following learner outcomes related to medication management: alcohol use disorder, OUD, and nicotine use disorder. Medication management of cannabis use disorder was not assessed in the pre- to postsurveys. Additionally, the didactic presentation topics that centered on alcohol, opioid, and nicotine use disorder resulted in a higher attendance rate with about 40% (n=6) to 50% (n=8) of the participants included in the paired-samples t test analysis attending the sessions, as compared to only 20% (n=3) of the aforementioned participant sample having attended the session centered on stimulant use disorder.

These findings indicate that the ECHO program’s content aligned with its stated learning objectives; met its learning objectives for the 3 themes where significant improvements were measured; and met its intent to address multiple substances in case presentations and discussions. While case presentations and discussions comprise from half to the majority of content in the sessions (30-35 minutes of a 60-minute session), content during sessions also includes faculty didactic presentations (20-25 minutes), which also addresses these 7 learning objectives and various substances but was not a part of the content analysis. Therefore, learner outcome improvements may also be a result of content addressed in didactic presentations.

While the Project ECHO model has been shown to be effective in training the primary care workforce [ 9 ], specifically on OUD [ 10 , 11 ] and addiction medicine [ 12 , 13 ], there has been no documentation, to our knowledge, of the ability of a team-based, comprehensive SUD and polysubstance-focused Project ECHO designed to improve learner outcomes (eg, knowledge, self-efficacy, and skills). Although Komaromy and colleagues [ 14 ] investigated the frequency of cases presented based on substance type in a comprehensive SUD-focused ECHO, a content analysis of the case presentation and discussion transcripts was not analyzed to either assess the frequency of substances or learning objectives. Furthermore, to our knowledge, this process has not been combined in a mixed method approach to compare learner outcomes with a content analysis to gauge the ability of an SUD-focused Project ECHO program to meet its stated learning objectives. Our results reported here align with this literature and expand to demonstrate that Project ECHO is a potential tool to effectively educate multidisciplinary providers in a comprehensive approach to SUD care.

This study has several strengths which promote the ability of the Project ECHO model in enhancing health care providers’ knowledge, self-efficacy, and skill associated with comprehensive SUD care. The focus of this study is unique as there is minimal research exploring the benefits and training ability of Project ECHO with a comprehensive SUD care focus. This study’s noteworthy strength is the use of a mixed methods design that presents a comprehensive evaluation correlating the content addressed in the case presentations and discussions to statistically significant learner outcomes to demonstrate how this telementoring continuing education series improved provider’s knowledge, skills, and self-efficacy to benefit participating providers and their practices.

Limitations

This study faced several limitations during data collection and analysis. The first limitation of this study was the limited sample size and low response rate. There was a decline between the number of participants who completed the preseries survey and postseries survey, resulting in a low comparative sample, which restricted the options for statistical analysis. Another limitation was generalizability; the results of this Project ECHO are limited to the target audience of medical providers, behavioral health providers, and care team members from the state of Ohio, which is not a representative sample of broader populations nationally. Additionally, participants self-selected to take part in the Project ECHO series, which presents the potential for self-selection bias. Another limitation this study faced was the lack of available or reliable data on Project ECHO and its ability to meet learning objectives and address multiple substances through providers’ knowledge, self-efficacy, skill, and attitudes. Furthermore, self-reported data to assess knowledge and skills, and self-reported data in general, could present participant biases and is difficult to corroborate with outcomes. The use of internally designed survey instruments instead of using validated instruments presents as a limitation. In light of these limitations, future studies in this subject matter should include a larger data set. Additionally, future studies using a nested analysis approach might provide more insight into how the learning objective themes coincide with the various illicit and nonillicit substance types and would be a useful analysis to contribute to the knowledge base. Another recommendation for future studies in this subject matter should include a deeper analysis of attendance dose and exposure to didactic topics to better understand the impact on changes in learner outcomes. Future research with greater validity will contribute to the significant gaps in literature regarding this subject.

Conclusions

The purpose of this research study was to assess the ability of CSUDC ECHO to both address and meet 7 learning objectives ( Textbox 2 ) and address multiple substances by analyzing (1) the frequency of exposure to the learning objective topics and substance types during case presentations and discussions and (2) participants’ knowledge, self-efficacy, skills, and attitudes related to the treatment of SUDs from pre- to postprogram. The results of this study indicate that CSUDC ECHO was able to both address and meet its learning objectives while addressing multiple substances, as demonstrated by improvements in learner knowledge, self-efficacy, and skills. All learning objective themes resulted in high frequencies and doses, appearing in a majority of case presentations throughout the series. These promising results suggest that Project ECHO is a potential tool to educate primary care providers, behavioral health providers, and care team members in a comprehensive approach to SUD assessment and treatment through complex case discussions combined with didactic learning for certain settings. As Project ECHO programs continue to be established globally and existing programs strengthen, further research examining the model’s ability to achieve positive learning outcomes and factors that may contribute to these outcomes (eg, frequency of topic dose) is needed to confirm the outcomes in larger population samples, additional topics of focus, and other geographical settings.

Acknowledgments

The authors would like to acknowledge our partners at Buckeye Health Plan and Ohio University Heritage College of Osteopathic Medicine. We would like to thank our funders, Centene Corporation through its subsidiary, Buckeye Health Plan; without their financial support, this work would not have been possible. We would like to thank the faculty that led the ECHO sessions, delivered didactic presentations, and provided high-quality case recommendations, including core faculty members Dana Vallangeon, doctor of medicine, Tracy Plouck, master of public administration, Amy Black, master of science in nursing, advanced practice registered nurse, nurse practitioner-certified, Ericka Ludwig, licensed professional clinical counselors applying for training supervision designation, licensed independent chemical dependency counselor, as well as guest faculty members. We would also like to thank our Weitzman Institute colleagues who helped with the content analysis: Zeba Kokan, Claire Newby, and Reilly Orner. To learn more about Weitzman Extension for Community Healthcare Outcomes programs, visit their website [ 15 ]. This project was supported by Buckeye Health Plan, a subsidiary of Centene Corporation. The views, opinions, and content expressed in this paper do not necessarily reflect the views, opinions, or policies of Buckeye Health Plan or Centene Corporation. The authors did not use generative artificial intelligence in any portion of this paper.

Data Availability

The data sets generated and analyzed during this study are not publicly available due to a portion of the data being deemed as exempt by the institutional review board and the institutional review board approving a waiver of informed consent for the exempt data, as well as the sensitive nature of the data, but are available from the corresponding author on reasonable request.

Authors' Contributions

MK wrote this paper, reviewed this paper, designed the evaluation plan, and performed the qualitative and statistical analyses. AP wrote this paper, reviewed this paper, and assisted with the evaluation design and approval. RM wrote this paper, reviewed this paper, performed the literature review, and assisted with the evaluation design and approval. NRN wrote this paper, reviewed this paper, and performed the literature review. KA critically reviewed this paper.

Conflicts of Interest

None declared.

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Abbreviations

Edited by T de Azevedo Cardoso; submitted 12.04.23; peer-reviewed by A Arbabisarjou, J Ford Ii; comments to author 12.09.23; revised version received 06.11.23; accepted 29.02.24; published 01.04.24.

©MacKenzie Koester, Rosemary Motz, Ariel Porto, Nikita Reyes Nieves, Karen Ashley. Originally published in JMIR Medical Education (https://mededu.jmir.org), 01.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Medical Education, is properly cited. The complete bibliographic information, a link to the original publication on https://mededu.jmir.org/, as well as this copyright and license information must be included.

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Disability Specific Summary - this consists of the information regarding the disability, cause of disability, diagnosis, treatment history and treatment plans. These are often used in claim management and other medical-related actions. Malpractice Incident Summary - this shows the cause of injury and its corresponding effect to the patient.
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Background: Substance use and overdose deaths make up a substantial portion of injury-related deaths in the United States, with the state of Ohio leading the nation in rates of diagnosed substance use disorder (SUD). Ohio's growing epidemic has indicated a need to improve SUD care in a primary care setting through the engagement of multidisciplinary providers and the use of a comprehensive ...

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