In describing your management, it is useful for the reader to know how long the patient was under care (how many weeks or months) and how many times they were treated. Additionally, you should be as specific as possible in describing the treatment that you used. It does not help the reader to simply say that the patient received “chiropractic care” or "physiotherapy". Specifically, what modalities did you use? If you used spinal manipulation or mobilization, it is best to name the technique, if a common name exists, and also to describe the procedure. Remember that your case study may be read by people who are not familiar with your specialty, and, even within your area, nomenclature for technique may not be well standardized.
The patient’s reports of improvement (or worsening) are useful. However, whenever possible we should try to use a well-validated method of measuring their improvement. For example, we might use data from visual analogue scales (VAS) for pain, or a journal of medication usage. If this information can be summarized in a table, or better yet a chart, it is more easily absorbed by the reader.
This portion of your case study might conclude with an indication of how and why treatment finished. Did you discharge the patient, and if so, why? Did the patient decide to terminate care? Did you refer the patient to another practitioner.
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