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Zhongwei Li
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skills/clinical-reports/assets/case_report_template.md
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skills/clinical-reports/assets/case_report_template.md
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# Clinical Case Report Template
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## Title
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[Insert descriptive title that includes "Case Report" or "Case Study" and indicates the clinical focus]
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Example: Unusual Presentation of Acute Appendicitis in an Elderly Patient: A Case Report
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## Author Information
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[Author names, affiliations, ORCID IDs]
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**Corresponding Author:**
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[Name]
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[Email]
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[Institution]
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## Keywords
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[2-5 keywords, preferably MeSH terms]
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Example: Appendicitis, Atypical presentation, Elderly, Diagnostic imaging
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## Abstract
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### Introduction
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[What is unique about this case? Why is it worth reporting? 1-2 sentences]
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### Patient Concerns
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[Primary symptoms and chief complaint]
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### Diagnosis
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[Final diagnosis, how it was reached]
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### Interventions
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[Key treatments provided]
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### Outcomes
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[Clinical outcome and follow-up status]
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### Lessons
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[Main takeaway messages for clinicians]
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**Word count:** [150-250 words]
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## Introduction
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[Background information - 2-4 paragraphs]
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**Paragraph 1:** Background on the condition
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- Epidemiology of the condition
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- Typical clinical presentation
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- Standard diagnostic approach
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- Current treatment guidelines
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**Paragraph 2:** Why this case is novel
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- What makes this case unusual or important
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- Gap in medical knowledge addressed
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- Literature review showing rarity or uniqueness
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- Clinical significance
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**Paragraph 3:** Objectives
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- Purpose of reporting this case
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- Learning points to be highlighted
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## Patient Information
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**Demographics:**
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- Age: [e.g., "A 72-year-old" or "A woman in her 70s"]
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- Sex: [Male/Female]
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- Ethnicity: [if relevant to case]
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- Occupation: [if relevant]
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**Medical History:**
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- Past medical history: [chronic conditions]
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- Past surgical history: [prior surgeries]
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- Family history: [relevant family history]
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- Social history: [tobacco, alcohol, occupation, living situation]
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**Medications:**
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- Current medications: [list with doses]
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- Allergies: [drug allergies and reactions]
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**Presenting Symptoms:**
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- Chief complaint: ["Patient's words" or clinical presentation]
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- Duration of symptoms
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- Severity and characteristics
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- Associated symptoms
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- Relevant review of systems
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## Clinical Findings
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**Physical Examination:**
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- Vital signs: [T, BP, HR, RR, SpO2]
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- General appearance: [overall state]
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- Systematic examination by organ system:
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- HEENT: [findings]
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- Cardiovascular: [findings]
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- Respiratory: [findings]
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- Abdomen: [findings]
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- Neurological: [findings]
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- Other relevant systems: [findings]
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**Pertinent Negatives:**
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[Important negative findings]
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## Timeline
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| Date/Time | Event |
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|-----------|-------|
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| [Day -X or Date] | [Initial symptom onset] |
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| [Day 0 or Date] | [Presentation to healthcare] |
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| [Day 0 or Date] | [Initial evaluation and tests] |
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| [Day X or Date] | [Diagnosis confirmed] |
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| [Day X or Date] | [Treatment initiated] |
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| [Day X or Date] | [Hospital discharge or follow-up] |
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| [Month X or Date] | [Long-term follow-up] |
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*Note: Use relative days (Day 0, Day 1) or approximate dates (Month 1, Month 3) to protect patient privacy*
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## Diagnostic Assessment
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### Initial Diagnostic Workup
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**Laboratory Tests:**
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| Test | Result | Reference Range | Interpretation |
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|------|--------|----------------|----------------|
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| [Test name] | [Value with units] | [Normal range] | [High/Low/Normal] |
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**Imaging Studies:**
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- [Modality] ([Date]): [Key findings]
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- [Include images if applicable, with labels and arrows pointing to key findings]
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**Other Diagnostic Procedures:**
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- [Procedure name] ([Date]): [Findings]
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### Differential Diagnosis
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**Diagnoses Considered:**
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1. [Primary differential]
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- Supporting evidence:
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- Evidence against:
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2. [Alternative diagnosis]
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- Supporting evidence:
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- Evidence against:
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3. [Additional differentials as appropriate]
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### Diagnostic Challenges
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[Describe any difficulties in reaching the diagnosis]
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- Atypical presentation
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- Misleading initial findings
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- Diagnostic delays
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- Complex decision-making
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### Final Diagnosis
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**Confirmed Diagnosis:** [Final diagnosis with ICD-10 code if applicable]
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**Diagnostic Reasoning:**
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[Explain how diagnosis was reached, key diagnostic features, confirmatory tests]
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## Therapeutic Intervention
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### Treatment Approach
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**Initial Management:**
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- [Immediate interventions]
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- [Supportive care]
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- [Monitoring]
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**Definitive Treatment:**
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1. **Pharmacological Interventions:**
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- [Drug name]: [Dose, route, frequency, duration]
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- Indication: [Why prescribed]
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- Response: [Patient response to treatment]
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2. **Procedural/Surgical Interventions:**
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- [Procedure name] performed on [date/day]
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- Indication: [Why performed]
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- Technique: [Brief description]
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- Findings: [Intraoperative or procedural findings]
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- Complications: [Any complications or none]
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3. **Other Interventions:**
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- [Physical therapy, dietary modifications, etc.]
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**Alternative Treatments Considered:**
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[Other treatment options that were considered and why they were not pursued]
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**Changes to Interventions:**
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[Any modifications to treatment plan]
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- Date of change:
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- Reason for change:
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- New intervention:
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## Follow-up and Outcomes
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**Immediate Outcome:**
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[Outcome during hospitalization or initial treatment period]
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- Clinical response:
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- Laboratory or imaging follow-up:
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- Complications:
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- Length of hospitalization (if applicable):
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**Short-term Follow-up:** ([Timeframe, e.g., 1 month])
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- Clinical status:
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- Follow-up tests:
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- Adherence to treatment:
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- Any issues or concerns:
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**Long-term Follow-up:** ([Timeframe, e.g., 6 months, 1 year])
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- Clinical status:
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- Recovery or resolution:
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- Functional status:
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- Quality of life:
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- Recurrence or complications:
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**Patient-Reported Outcomes:**
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[Symptoms, quality of life, patient satisfaction]
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## Discussion
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**Paragraph 1: Summary and Significance**
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[Briefly summarize the case and state its significance]
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**Paragraph 2: Literature Review**
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[Review similar cases in the literature]
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- Number of similar cases reported
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- Comparison to this case
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- What is novel about this case
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- [Cite relevant references]
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**Paragraph 3: Clinical Implications**
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[What can clinicians learn from this case?]
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- Recognition of atypical presentations
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- Diagnostic pearls
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- Treatment considerations
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- When to consider this diagnosis
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**Paragraph 4: Pathophysiology or Mechanism (if applicable)**
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[Explain underlying mechanism, why this occurred, contributing factors]
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**Paragraph 5: Strengths and Limitations**
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[Acknowledge limitations of case report]
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- Single case report limitations
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- Cannot establish causation
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- Generalizability concerns
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- Strengths of comprehensive evaluation
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**Paragraph 6: Future Directions**
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[Unanswered questions, areas for future research]
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## Learning Points
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- [Point 1: Concise, actionable clinical lesson]
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- [Point 2: Key diagnostic or treatment pearl]
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- [Point 3: When to consider this diagnosis]
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- [Point 4: (optional) Additional takeaway]
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## Patient Perspective
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[Optional but encouraged: Patient's own description of experience, in their own words if possible]
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"[Patient quote describing their experience, symptoms, treatment, or outcome]"
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[Or narrative description of patient's perspective, impact on quality of life, satisfaction with care]
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## Informed Consent
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Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
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[OR if patient deceased/unable to consent:]
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Written informed consent was obtained from the patient's next of kin for publication of this case report, as the patient was deceased [or unable to provide consent due to...] at the time of manuscript preparation.
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## Conflicts of Interest
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The authors declare that they have no conflicts of interest.
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## Funding
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This case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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[OR: This work was supported by [funding source and grant number]]
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## Acknowledgments
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[Acknowledge contributors who do not meet authorship criteria, providers who cared for patient, etc.]
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## References
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[Format according to journal requirements - typically AMA, Vancouver, or APA]
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1. [First reference - Author(s). Title. Journal. Year;Volume(Issue):Pages.]
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2. [Second reference...]
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---
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## CARE Checklist Completion
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Use the CARE checklist to ensure all required elements are included:
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- [ ] Title includes "case report"
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- [ ] Keywords provided (2-5)
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- [ ] Structured/unstructured abstract
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- [ ] Introduction with background and novelty
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- [ ] Patient demographics (de-identified)
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- [ ] Clinical findings
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- [ ] Timeline
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- [ ] Diagnostic assessment
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- [ ] Therapeutic interventions
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- [ ] Follow-up and outcomes
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- [ ] Discussion with literature review
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- [ ] Patient perspective (if possible)
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- [ ] Informed consent statement
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- [ ] All 18 HIPAA identifiers removed
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- [ ] References formatted correctly
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- [ ] Figures/tables labeled and referenced
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- [ ] Word count within journal limits
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---
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## De-identification Checklist
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Verify all HIPAA identifiers removed:
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- [ ] Names (patient, family, providers)
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- [ ] Geographic locations smaller than state
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- [ ] Exact dates (use year only or relative time)
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- [ ] Phone numbers
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- [ ] Email addresses
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- [ ] Medical record numbers
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- [ ] Account numbers
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- [ ] License numbers
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- [ ] Device serial numbers
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- [ ] URLs
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- [ ] IP addresses
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- [ ] Biometric identifiers
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- [ ] Full-face photos (cropped or blurred)
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- [ ] Any other identifying information
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---
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**Notes:**
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- Adapt this template to your specific journal's requirements
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- Check word count limits (typically 1500-3000 words)
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- Follow journal's reference style
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- Include institutional review/ethics exemption if applicable
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- Consider attaching CARE checklist when submitting
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