Rédaction de cas cliniques

A clinical case report is a structured narrative that communicates a patient's story, findings, and management. It helps healthcare professionals share information, support clinical reasoning, and ensure continuity of care. In English, the most common format is the SOAP note: Subjective, Objective, Assessment, and Plan. Mastering this structure allows you to present cases clearly and professionally in an international medical environment.

The subjective section captures the patient's experience in their own words. Start with the chief complaint, ideally a direct quote. Then detail the history of present illness using a systematic approach like OPQRST (Onset, Provocation, Quality, Radiation, Severity, Time). Include relevant past medical history, medications, and social history. This part builds the clinical picture before any examination.

The objective section includes measurable data: vital signs, physical examination findings, and test results. Describe findings systematically, often from head to toe, using precise anatomical terms. Avoid vague language; instead of 'normal', record specific numbers. For example, write 'BP 120/80 mmHg, HR 72 bpm, RR 16/min, Temp 37.0°C, SpO2 98%' rather than 'vital signs normal'.

The assessment is your clinical reasoning: list the most likely diagnosis and differential diagnoses. The plan outlines the next steps: diagnostic tests, treatments, referrals, and patient education. Write in clear, concise English, using bullet points or numbered lists. This section shows your ability to interpret data and make decisions, which is essential for effective handovers and medical records.