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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 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; 2023 Jan-.

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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

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

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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

Submit ancillary resource

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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Page 1 of 137

Cauda equina syndrome in a patient with human immunodeficiency virus and secondary central nervous system lymphoma: a case report

Secondary central nervous system lymphoma (SCNSL) is a known complication of immunocompromised patients with most cases involving the brain parenchyma. Reports of cauda equina syndrome (CES) caused by SCNSL ar...

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Congenital erythropoietic porphyria presenting with recurrent epistaxis: a case report

Congenital erythropoietic porphyria (CEP), also known as pink tooth or Gunther disease, is a rare hereditary disorder caused by an enzyme mutation in the heme biosynthesis pathway, which leads to the accumulat...

Inflammatory dilated cardiomyopathy associated with psoriasis: a case report

Psoriasis is a chronic inflammatory skin disease with a genetic basis. Psoriasis is accepted as a systemic, immune-mediated disease. Hypertension, obesity, metabolic disorders including diabetes mellitus and h...

Reciprocal relations between cardiovascular disease, employment, financial insecurity, and post cardiac event recovery among Māori men: a case series

Disparities in cardiovascular outcomes between Māori and non-Māori persist despite technological advances in the treatment of cardiovascular disease and improved service provision. Little is known about how so...

Acute cytomegalovirus proctitis and epididymitis acquired via sexual transmission in an immunocompetent patient: a case report

We present a case report of an immunocompetent host with presumed sexually transmitted cytomegalovirus proctitis and epididymitis, where there currently is a sparsity of published data.

Magnetic resonance imaging and next-generation sequencing for the diagnosis of cystic echinococcosis in the intradural spine: a case report

Cystic echinococcosis (CE) is a parasitic zoonotic disease caused by the larval stage of Echinococcus granulosus . The liver and lungs are the most common sites for infection. Infection of the intradural spine is ...

New challenges in management of phenylketonuria in pregnancy: a case report

Phenylketonuria (PKU) is an autosomal recessive disease that belongs to a group of disorders resulting from inborn errors of protein metabolism. It was the first disease included in neonatal screening. Neonata...

Foveal cone loss in tamoxifen maculopathy: a case report

Tamoxifen is used in low dose concentrations (20–40 mg per day) as a therapy for breast cancer but is known to have ocular side effects. In this case report, the foveal cone integrity in a tamoxifen-treated pa...

Management of traumatic cervical epidural hematoma in patients on Xa-inhibitors: a case report and review of the literature

Cervical epidural hematoma (CEH) is defined as a collection of blood in the suprameningeal space. Mechanisms of this rare pathology include spontaneous, postsurgical, and traumatic as the main subtypes. This u...

Spinal cord stimulator explant caused by post-incisional cellulitis secondary to Varicella Zoster Virus (shingles) infection: a case report

Spinal Cord Stimulation (SCS) is a well-established therapy for refractory neuropathic pain, known for its safety and minimally-invasive nature. However, complications, including surgical site infections (SSIs...

Endoscopic stent placement for the management of gastro-pleural and gastro-cutaneous fistula post laparoscopic sleeve gastrectomy: a case report

Gastro-pleural and gastro-cutaneous fistulae formation are rare yet life-threatening complications post-bariatric surgery. To our knowledge so far only limited cases of gastro-pleural and gastro-cutaneous fist...

Clopidogrel-induced non-diabetic hypoglycemia reported from Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: a case report

Recurrent episodes of hypoglycemia may be caused by several factors, including drugs, critical illnesses, hormonal deficiency, non-islet cell tumor endogenous hyperinsulinism, and accidental, surreptitious, or...

Superior mesenteric artery syndrome and anorexia nervosa: a case report

Superior mesenteric artery (SMA) syndrome is an underdiagnosed complication in anorexia nervosa (AN) patients, which results from weight loss-induced atrophy of the mesenteric fat pad, causing compression of t...

Mycosis fungoides with spongiosis: a case report

Mycosis fungoides (MF) is the most common form of cutaneous T-cell lymphoma (CTCL). CTCL are an uncommon, heterogeneous group of non-Hodgkin lymphomas (NHLs) of T- and B-cell origin where the skin is the prima...

Transplant with MZ genotype liver: what is the clinical pulmonary picture after 30 years? a case report and review of the literature

Alpha-1 antitrypsin, also known as alpha1 proteinase inhibitor, is a protein 90% synthesized by hepatocytes. Alpha-1 antitrypsin deficiency should be suspected if patients have unexplained emphysema or liver d...

Lethal pulmonary embolism in a pregnant woman with severe acute respiratory syndrome coronavirus-2 receiving prophylactic anticoagulation: a case report

A limited number of studies have described thrombotic complications in pregnant women with COVID-19. Here we report on fatal pulmonary embolism in a pregnant woman with laboratory confirmed SARS-CoV-2 infection.

Correction: Colonic medullary carcinoma: an exceedingly rare type of colorectal malignancy: a case report and review of the literature

The original article was published in Journal of Medical Case Reports 2023 17 :434

The importance of intraoperative echocardiography in the early detection of mitral regurgitation as a postsurgical sequel of aortic valve replacement: a case report

Mitral leaflet perforation (MLP) can rarely be a consequence of aortic valve replacement (AVR), resulting in mitral regurgitation (MR). Determining the cause and severity of MLP following AVR is crucial in pre...

Epicardial pacing lead implantation for congenital complete atrioventricular block immediately after birth: a case report

The incidence of congenital complete atrioventricular block is estimated to be 1 per 20,000 deliveries. In the fetal period, the fetal mortality rate is high, but the treatment strategy has not yet been establ...

Correction to: Dual paraneoplastic syndromes in a patient with small cell lung cancer: a case report

The original article was published in Journal of Medical Case Reports 2011 5 :318

Multimodal treatment, including extracorporeal shock wave therapy, for refractory chronic tension-type headache: a case report

Few reports have described multidisciplinary treatment, including extracorporeal shock wave therapy, for patients with refractory chronic tension-type headache. In this study, we conducted multidisciplinary tr...

Hoffmann’s syndrome in the differential work-up of myopathic complaints: a case report

Hoffmann’s syndrome is a rare form of hypothyroid myopathy in adults, which is mainly characterized by muscular weakness and muscular pseudohypertrophy.

Functional reconstruction of elbow flexion with latissimus dorsi muscle rotational transfer: two case reports

We report two cases of biceps brachii and brachialis paralysis due to musculocutaneous nerve injury in which elbow joint flexion was reconstructed using rotational transfer of the latissimus dorsi muscle with ...

Dedifferentiated endometrial carcinoma metastasis to axillary lymph node: a case report

We present an unusual case of a left axillary lymph node metastasis from a primary dedifferentiated endometrial carcinoma. This pattern of metastasis is likely the result of circulating tumor cells reaching th...

Course of an unplanned and unexpected pregnancy in a 39 year-old patient with Complex bladder extrophy: a case report

With improved operative techniques pregnancy rates have been rising in patients with anomalies of the extrophy-epispadias-complex, including also female patients with bladder extrophy. Specific risks around pr...

Acute osteomyelitis, thrombophlebitis, and pulmonary embolism: a case report

Septic pulmonary embolism (SPE), deep vein thrombophlebitis (DVT), and acute osteomyelitis (AOM) form a triad that is rarely seen in children and is usually associated with a history of trauma on long bones. U...

Durable effects of deep brain ultrasonic neuromodulation on major depression: a case report

Severe forms of depression have been linked to hyperactivity of the subcallosal cingulate cortex. The ability to stimulate the subcallosal cingulate cortex or associated circuits noninvasively and directly wou...

Refractory drug-induced systemic small-vessel vasculitis with two varied extracutaneous manifestations: a case report and review of the literature

Clopidogrel and ticagrelor are rarely reported to cause vasculitis via drug hypersensitivity reaction, largely mediated by T cells and immunoglobulin E (IgE). Despite therapeutic advances, the etiology of refr...

The co-occurrence of Kikuchi–Fujimoto disease and systemic lupus erythematosus: a case report

Kikuchi–Fujimoto disease is an uncommon systemic disease that mostly affects young women. Kikuchi–Fujimoto disease typically manifests as necrotizing lymphadenopathy, which frequently follows by a fever; howev...

Ventricular septal defect associated with aortic regurgitation and ascending aortic aneurysm: a case report

Ventricular septal defect (VSD) is one of the most common congenital cardiac anomalies. Patients with perimembranous VSD may have aortic regurgitation (AR) secondary to prolapse of the aortic cusp.

Congenital lower urinary tract obstruction with spontaneous fetal bladder rupture due to posterior urethral valves: a case report

Congenital lower urinary tract obstruction (LUTO) is a rare but significant condition affecting fetal urinary tract development. LUTO has a range of etiologies, with posterior urethral valves (PUV) being the m...

Dural arteriovenous fistula with spinal dural arteriovenous fistula: a case report and review of the literature

This paper analyzed the cases of dural arteriovenous fistula (DAVF) with spinal dural arteriovenous fistula (SDAVF) in the diagnosis and treatment process.

Chronic bilateral dacryoadenitis caused by SARS-CoV-2 infection: a case report

Dacryoadenitis is inflammation of the lacrimal gland, mainly caused by viral infection. It can also be caused by bacterial pathogens and non-infectious processes such as auto-immune diseases and malignancy. Ch...

Pyelo-hepatic abscess caused by staghorn stone infection: a case report

The most common source of pyogenic liver abscess is biliary tract infection. Other less common routes include the spread of bacteria from distant foci. However, direct extension of a perinephric infection focu...

Concurrence of familial Mediterranean fever and Behçet’s disease: a case report and review of the literature

Familial Mediterranean fever and Behçet’s disease are distinct disorders that are prevalent in the Mediterranean and Middle Eastern populations. They are characterized by unprovoked inflammatory episodes cause...

Late diagnosis of respiratory syncytial virus and influenza co-infection during coronavirus disease 2019 pandemic: a case report

Respiratory syncytial virus (RSV)-induced disease is one of the important causes of flu-like illness in older adults and can cause serious disease in those who are at high-risk medical conditions. During coron...

Treatment of severe metformin-associated lactic acidosis with renal replacement therapy and tris-hydroxymethyl aminomethane: a case report

Type B lactic acidosis is a rare but serious side effect of metformin use. The risk of metformin-associated lactic acidosis is elevated in renal or liver impairment, heart failure and in metformin overdose. Me...

Misdiagnosed metabolic bone abnormality: a case report

Metabolic bone disease causes significant morbidity and mortality, especially when misdiagnosed. With genetic testing, multiple disease pathologies can be analyzed.

Cutaneous metastasis from cervical cancer to the scalp and trunk: a case report and review of the literature

An estimated 119,300 new cases of cervical cancer occur annually in China, accounting for 372,00 deaths. Cutaneous metastasis from cervical cancer is a rare event, with an incidence of 0.1–1.3% and typically a...

Colonic medullary carcinoma: an exceedingly rare type of colorectal malignancy: a case report and review of the literature

Medullary carcinoma of the colon is a rare subtype of colorectal cancer that has a unique, and sometimes varied, clinical and histologic profile. It usually presents in adult patients older than 50 years. Here...

The Correction to this article has been published in Journal of Medical Case Reports 2023 17 :483

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) and Human Immunodeficiency virus infection: dilemmas in diagnosis and management: a case series

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a recently described autoimmune inflammatory disorder of the central nervous system (CNS). There is limited data on the association be...

Chronic shoulder injury related to vaccine administration following coronavirus disease 2019 vaccination: a case report

Shoulder injury related to vaccine administration, defined as shoulder pain and limited range of motion occurring after administration in the upper arm, has been previously reported. The symptom resolved compl...

Gradual loaded exercise of knee extension muscles using an orthosis after wide resection of a femoral sarcoma and quadriceps muscle: a case report

Details of improved gait ability after wide resection of soft tissue sarcomas that necessitate removal of portions of the quadricep muscle have not yet been reported. We describe a patient with improved gait a...

Memantine administration prevented chorea movement in Huntington’s disease: a case report

Huntington’s disease is an autosomal dominant inherited disorder characterized by personality changes (such as irritability and restlessness) and psychotic symptoms (such as hallucinations and delusions). When...

Severe thrombocytopenia induced by tirofiban after percutaneous coronary intervention: a case report

Tirofiban is a nonpeptide glycoprotein IIb/IIIa receptor antagonist used widely in patients subjected to percutaneous coronary intervention. While the usage of tirofiban sets an important clinical benefit, sev...

Thyrotoxicosis as a rare presentation in acute suppurative thyroiditis: a case report

Acute suppurative thyroiditis is a rare and potentially life-threatening disease. A few cases of acute suppurative thyroiditis associated with thyrotoxicosis have been reported in adults. We report a case of a...

The successful treatment of a Gustilo–Anderson type IIIc distal leg injury with a large bone defect in elderly patient with severe osteoporosis: a case report

Gustilo–Anderson type IIIc tibial open fracture with large bone defects in elderly patients with severe osteoporosis is a rare injury that may be a challenging clinical scenario.

Hereditary chromosomal 9 inversion (p22q13) 9 as a cause for recurrent pregnancy loss: a case report

Chromosomal aberrations are as common as 13.8% in the infertile population. The incidence of pericentric inversion of chromosome 9 is approximately 1–3%. However, although these inversions do not alternate phe...

An effective treatment in Erdheim Chester disease: vemurafenib: a case report

Erdheim Chester disease (ECD) is a rare disease with multisystemic involvement in the group of non-langerhans cell histiocytosis. Although nearly 100 years have passed since its definition, the number of cases...

Surgical technique of spine-shortening vertebral osteotomy for adult tethered cord syndrome: a case report and review of the literature

Miyakoshi et al. reported three cases of tethered cord syndrome treated by spine-shortening vertebral osteotomy, which provided relief of the patients’ symptoms with no complications. Although the details of thes...

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FREE 10+ Medical Case Study Samples & Templates in MS Word | PDF

How is a medical case study done? In the American medical drama series titled House, you can see Dr. House and his team of doctors do a little huddle and a lot of whiteboard scribbling. Now, they’re actually not having a meeting, but they’re conducting a medical case study of their patient. Medical case studies are commonplace for doctors, especially those who are working in the hospital. Studying the case of each patient allows doctors to find the best treatment plan based on the patient’s condition. So, how does this medical case study work? Let’s find out.

Medical Case Study

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Once complete, medical case studies are reported to hospital heads for further research. Here, we have medical case study samples and templates to help you with making a presentable case report output.

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A medical case study is an in-depth or thorough investigation of a health condition, particularly those that are rare or illnesses that are elicited differently from the usual. Data gathering and analysis of data play an important role in this study because it is the means by which doctors and other medical practitioners can correctly diagnose the patient’s condition. Doctors go through trial and error before an actual diagnosis is decided. There are risks in a trial and error process; that is why the benefits should always outweigh the risks when it is done. The focus of a medical case study is on the identification and treatment of a known or unknown disease. Before the case is put into writing, a brainstorming session between the members of the medical team takes place. This is where the exchange of information and the realization of the data gathered is used.

The information gathered for a medical case study is biological. They are information about the patient’s past and present day-to-day activities. The methods used in a case study are determined through research. Different methods are essential in the study because it helps in making suitable materials for the case. Medical case studies greatly help in furthering the knowledge of doctors and other medical professionals in their field of expertise. It is a study material that applies both medical theory and actual practice. Similar case studies include a nursing case study and a patient case study .

A medical case study requires time, patience, and a lot of knowledge on the case at hand. Formatting the study is simple. The difficult part is putting together all of the information gathered and make some sense out of it that will help find a treatment for a patient’s illness. To help you prepare your medical case study, here are a few steps that will help you get started.

Base the design, style, and format of your case study according to your audience or readers. Using the audience’s references over your style will help them effectively understand your medical presentation, especially if it is about a critical case. Using the appropriate case study template is helpful.

You will find more than one illness in the same patient because of the complications brought about by the actual disease. While it is necessary to include all relevant findings about the patient, you should be specific about the main focus of the study and explain how other illnesses are related to it.

It’s possible that the same case has been studied by other medical professionals before. It could be from another hospital or another country in a different language. Your research will be more effective if you make use of previously published materials. It will help you gain more understanding of the illness and make the necessary preparations to complete the study.

Another easy to gather information by interviewing the patient and the people surrounding this patient. From them, you can get valuable information like habits and vices that the patient may not be willing to share.

Once you have all the data you need, proceed with connecting the relation of one information with another. If your case analysis is missing something, do another research or conduct another interview until you have the missing piece.

Now that you have all the prices of information together, you can start working on your case study presentation. Make sure to use guides or references to make the task easier and convenient.

Medical case studies are conducted by doctors and focus more on the disease and its treatment. A nursing case study, on the other hand, is conducted by nursing students and licensed nurses. While a nursing case study also includes treatment of the disease, its main focus is on the care of the patient before, during, and after treatment. It is more about making the patient feel at ease throughout the treatment of the disease.

A medical case study is most useful in studying rare diseases with a long latency period. It allows the researcher more time to study how an individual is infected and how the illness manifests. They are also less time consuming compared to actual large scale research.

New information about a known disease can be learned and communicated by medical professionals through a medical case study. That is why even if it is one of the earliest forms of medical communication, the study is still practiced in the present. If you’re learning how to make a medical case study, you will find the samples and templates above useful. You can even download them for free!

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Harvard T.H. Chan School of Public Health Case-Based Teaching & Learning Initiative

Teaching cases & active learning resources for public health education, case library.

The Harvard Chan Case Library is a collection of teaching cases with a public health focus, written by Harvard Chan faculty, case writers, and students, or in collaboration with other institutions and initiatives.

Use the filters at right to search the case library by subject, geography, health condition, and representation of diversity and identity to find cases to fit your teaching needs. Or browse the case collections below for our newest cases, cases available for free download, or cases with a focus on diversity.

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Many of our cases are available for sale through Harvard Business Publishing in the Harvard T.H. Chan case collection . Others are free to download through this website .

Cases in this collection may be used free of charge by Harvard Chan course instructors in their teaching. Contact Allison Bodznick , Harvard Chan Case Library administrator, for access.

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Teaching notes are available as supporting material to many of the cases in the Harvard Chan Case Library. Teaching notes provide an overview of the case and suggested discussion questions, as well as a roadmap for using the case in the classroom.

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Teaching notes for cases available through Harvard Business Publishing may be downloaded after registering for an Educator account .
To request teaching notes for cases that are available for free through this website, look for the "Teaching note available for faculty/instructors " link accompanying the abstract for the case you are interested in; you'll be asked to complete a brief survey verifying your affiliation as an instructor.

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Faculty and instructors with university affiliations can register for Educator access on the Harvard Business Publishing website, where many of our cases are available . An Educator account provides access to teaching notes, full-text review copies of cases, articles, simulations, course planning tools, and discounted pricing for your students.

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Atkinson, M.K. , 2023. Organizational Resilience and Change at UMass Memorial , Harvard Business Publishing: Harvard T.H. Chan School of Public Health. Available from Harvard Business Publishing Abstract The UMass Memorial Health Care (UMMHC or UMass) case is an examination of the impact of crisis or high uncertainty events on organizations. As a global pandemic unfolds, the case examines the ways in which UMMHC manages crisis and poses questions around organizational change and opportunity for growth after such major events. The case begins with a background of UMMHC, including problems the organization was up against before the pandemic, then transitions to the impact of crisis on UMMHC operations and its subsequent response, and concludes with challenges that the organization must grapple with in the months and years ahead. A crisis event can occur at any time for any organization. Organizational leaders must learn to manage stakeholders both inside and outside the organization throughout the duration of crisis and beyond. Additionally, organizational decision-makers must learn how to deal with existing weaknesses and problems the organization had before crisis took center stage, balancing those challenges with the need to respond to an emergency all the while not neglecting major existing problem points. This case is well-suited for courses on strategy determination and implementation, organizational behavior, and leadership.

The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country.

Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department. The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center.

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Kerrissey, M.J. & Kuznetsova, M. , 2022. Killing the Pager at ZSFG , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract This case is about organizational change and technology. It follows the efforts of one physician as they try to move their department past using the pager, a device that persisted in American medicine despite having long been outdated by superior communication technology. The case reveals the complex organizational factors that have made this persistence possible, such as differing interdepartmental priorities, the perceived benefits of simple technology, and the potential drawbacks of applying typical continuous improvement approaches to technology change. Ultimately the physician in the case is not able to rid their department of the pager, despite pursuing a thorough continuous improvement effort and piloting a viable alternative; the case ends with the physician having an opportunity to try again and asks students to assess whether doing so is wise. The case can be used in class to help students apply the general concepts of organizational change to the particular context of technology, discuss the forces of stasis and change in medicine, and to familiarize students with the uses and limits of continuous improvement methods.

Yatsko, P. & Koh, H. , 2021. Dr. Joan Reede and the Embedding of Diversity, Equity, and Inclusion at Harvard Medical School , Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract For more than 30 years, Dr. Joan Reede worked to increase the diversity of voices and viewpoints heard at Harvard Medical School (HMS) and at its affiliate teaching hospitals and institutes. Reede, HMS’s inaugural dean for Diversity and Community Partnership, as well as a professor and physician, conceived and launched more than 20 programs to improve the recruitment, retention, and promotion of individuals from racial and ethnic groups historically underrepresented in medicine (UiMs). These efforts have substantially diversified physician faculty at HMS and built pipelines for UiM talent into academic medicine and biosciences. Reede helped embed the promotion of diversity, equity, and inclusion (DEI) not only into Harvard Medical School’s mission and community values, but also into the DEI agenda in academic medicine nationally. To do so, she found allies and formed enduring coalitions based on shared ownership. She bootstrapped and hustled for resources when few readily existed. And she persuaded skeptics by building programs using data-driven approaches. She also overcame discriminatory behaviors and other obstacles synonymous with being Black and female in American society. Strong core values and sense of purpose were keys to her resilience, as well as to her leadership in the ongoing effort to give historically marginalized groups greater voice in medicine and science.

Cases Available for Free Download

Weinberger, E. , 2014. Some Skin in the Game: Negotiating the End of a Campus Health Menace , Harvard T.H. Chan School of Public Health: Strategic Training Initiative for the Prevention of Eating Disorders (STRIPED). Download free of charge Abstract Fictitious Colburn University boasts many “amenities” for its students, including cafes, a gymnasium, and U.V. tanning salon Campus Tans. Meredith Tang, a law student originally from Australia, and Barbara Holly, a public health student, cannot believe that this insidious industry has infiltrated campus life and worse yet seems to be promoted by the school, or at least is allowed to advertise on campus. Soon these students turned activists begin a campaign to evict the salon; however, they quickly discover that evicting Campus Tans may not be as easy as they thought. As the story ends, the student activists sit down to a meeting with school officials and the owner of the salon to negotiate an agreement that protects the health of Colburn students while balancing the interests of diverse stakeholders. Teaching note available for faculty/instructors .

Teaching note available for faculty/instructors .

2018. Western Public Health Casebooks: Cases from the Schulich Interfaculty Program in Public Health , Western University: Schulich School of Medicine & Dentistry. Access online Abstract A collection of cases written by MPH students of the Schulich Interfaculty Program in Public Health at Western University, Canada. These casebooks--from 2015, 2016, 2017, and 2018--may be copied and used free of charge without permission for any educational uses by an accredited educational institution.

In August of 2020, after a day treating patients, John McAdams, MD, gets ready to meet with a young couple from the community. He is excited to share the latest progress on his institution’s Cancer Treatment and Control Center, which is set to open in 3 years. The $230+ million project is something that Dr. McAdams has been building in his mind for years. Its brick and mortar location will strive to be a truly different cancer center that emphasizes population health alongside acute treatment. Cutting edge technologies and innovative public health initiatives working in tandem will close the gap between rural and urban cancer patient outcomes.

After decades of diligence, vision, and advocacy from John, Midwest Regional Health (MRH) has purchased the physical location of what will be a state-of-the-art cancer treatment and control center—a rarity for rural America. The site is on the main campus and will be connected to the inpatient and pediatric hospitals by tunnels to have the cancer center be better integrated into the continuum of cancer care than an outpatient center at a separate location. According to John, “The architects have worked very hard to make the center what we wanted…very welcoming and reassuring but intertwining all the workings of the various departments.”

However, with just three years before the grand opening, questions remain about how to structure the management of the cancer center relative to the medical center and the oncology service line, how to expand the research base in oncology, and how to drum up excitement and support in the community.

Chai, J., Gordon, R. & Johnson, P. , 2013. Steubenville, Ohio: A Community's Reckoning of Responsibility , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case explores the role of social media in bringing a sexual assault incident to national attention and to trial. Two popular high school athletes sexually assaulted a teenage girl at a party. Despite evidence of their guilt based on their own boasts and eye witnesses, the community refused to hold the boys accountable for their actions because of their status as star athletes on the local football team. "Steubenville, Ohio: A Community’s Reckoning of Responsibility" is part of a case series on violence against women that illustrates the critical role of leadership through an examination of how social factors influence women’s health. Students analyze the situations described by considering the circumstances that placed each protagonist in vulnerable positions. Participants examined the commonalities and differences of these situations in an effort to understand the circumstances that affect women’s well-being. Additionally, using the cases as a framework, students analyzed the connections between collective outrage, reactive action, and leadership.

Focus on Diversity, Equity, and Inclusion

This module will present two unfolding case studies based on real-world, actual events. The cases will require participants to review videos embedded into three modules and a summary module: Introduction to Concepts of Social Determinant of Health and Seeking Racial Equity Case Study on Health and Healthcare Context - Greensboro Health Disparities Collaborative (GHDC) Case Study on Social and Community Context - Renaissance Community Cooperative (RCC) Summary (Optional)

The learning objectives for the modules are related to achieving the Healthy People 2020 Social Determinants of Health Objectives – specifically the (1) Health and Healthcare Context, and (2) Social and Community Context.

Johnson, P. & Gordon, R. , 2013. Hauwa Ibrahim: What Route to Change? , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case explores Nigerian attorney Hauwa Ibrahim’s defense of a woman charged with adultery by Islamic Shariah law. One of Nigeria’s first female lawyers, Ibrahim develops a strategy to defend a young married woman, Amina Lawal, against adultery charges that could potentially, if the court judged against her, result in her death. While many Western non-governmental organizations and advocacy groups viewed Lawal’s case as an instance of human rights abuse and called for an abolition of the Shariah-imposed punishment, Ibrahim instead chose to see an opportunity for change within a system that many – especially cultural outsiders – viewed as oppressive. Ibrahim challenged the dominant paradigm by working within it to create change that would eventually reverberate beyond one woman’s case. Willing to start with a framework that saw long-term opportunity and possibility, Ibrahim developed a very measured change approach and theory framed in seven specific principles. Additionally, Ibrahim’s example of challenging her own internal paradigms while also insisting that others do the same invites students to examine their own internal systems and paradigms.

Guerra, I., et al. , 2019. SALUDos: Healthcare for Migrant Seasonal Farm Workers , Harvard University: Social Medicine Consortium. Download free of charge Abstract The SALUDos program began in 2008 as a response to an influx of migrant seasonal farm workers (MSFWs) at a mobile medical unit serving homeless persons in Santa Clara County in Northern California. The program offered patients free and low-cost primary care services, linkage to resources, and advocacy. As the farm workers involved in this program became more involved in their primary care, they advocated for evening hours, transportation, linkage to coverage programs, and health education resources to better understand their medical and psychological conditions. During continual modifications of the SALUDos program, the team sought to understand and address large-scale social forces affecting migrant health through interventions to mitigate health inequities. Teaching note available for faculty/instructors.

This case describes and explores the development of the first medical transitions clinic in Louisiana by a group of community members, health professionals, and students at Tulane Medical School in 2015. The context surrounding health in metro New Orleans, the social and structural determinants of health, and mass incarceration and correctional health care are described in detail. The case elucidates why and how the Formerly Incarcerated Transitions (FIT) clinic was established, including the operationalization of the clinic and the challenges to providing healthcare to this population. The case describes the central role of medical students as case managers at the FIT clinic, and how community organizations were engaged in care provision and the development of the model. The case concludes with a discussion of the importance of advocacy amongst health care professionals.

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Singer, S. , 2013. Surgical Safety Simulation Exercise , Harvard T.H. Chan School of Public Health. Abstract In this simulation exercise, students are given the opportunity to think critically about the role of motivation and organizational context in implementing a process innovation. Students work in teams of four to six people to develop recommendations for a hospital president on the best ways to implement a surgical safety checklist. Simulation available upon request from author .

Quelch, J.A. & Rodriguez, M. , 2014. Royal Caribbean Cruises, Ltd.: Safety, Environment and Health , Harvard Business Publishing. Available from Harvard Business Publishing Abstract In January 2014, Gary Bald, senior vice president of Safety, Environment and Health at Royal Caribbean Cruise Lines (RCL), prepared for a review meeting with the company's chief executive, Adam Goldstein, and chairman, Richard Fain. Prior to joining RCL in 2006, Bald had spent 28 years with the Federal Bureau of Investigation. After seven years of upgrading security for the cruise line, Bald stated, "We've come a long way, but what keeps me up at night is what I don't know." As he prepared for his meeting with Fain and Goldstein, Bald considered whether his department's current initiatives would be sufficient to maintain RCL's position at the cutting edge of cruise industry best practice, and whether RCL could and should differentiate itself in marketing from its competitors in the areas of safety, environment and health.

Quelch, J.A. & Rodriguez, M. , 2013. Glaxosmithkline in China (Parts A, B, & C) , Harvard Business Publishing. Available from Harvard Business Publishing Abstract Four GlaxoSmithKline employees were accused of bribing Chinese health care workers to prescribe the company's drugs. The accusations brought to light the questionable incentive structures of the Chinese health care system and the pressure on companies to adhere to local customs while still observing local laws.

Siegrist, R. , 2017. Carlsbad Home Care--The Alternatives , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Doing a breakeven analysis for Carlsbad Home Care helped Director Louise Tucker better understand how many more visits she needed to eliminate her deficit. However, she wasn’t sure that there was really demand in the community for more nursing, physical therapy or social service visits to allow her to increase visit volume. She also knew that negotiating a higher per visit price from their affiliated HMO was highly unlikely. If increasing volume and raising the price for visits were not feasible, she wondered what else she should be thinking about. She decided she should explore alternatives that would look at her specific programs, staffing approaches, and general expenses. In discussions with her controller, she arrived at five alternatives for consideration.

Gordon, R. & Moon, S. , 2014. Haiti in the Time of Cholera , Harvard University: Global Health Education and Learning Incubator. Access online Abstract This case examines the United Nations' reactions to the cholera epidemic in Haiti and illuminates contemporary gaps in global governance. In January, 2010, an earthquake devastated Haiti, the poorest country in the Western Hemisphere. The public health community anticipated Haiti to be at risk for many health threats, but did not consider a cholera outbreak a likely possibility. However, in October of that year, the first case of cholera in more than 100 years was reported, sparking a cholera epidemic in Haiti. Scientific evidence later linked the original source of the cholera to poor sanitation management practices at a United Nations (UN) peacekeepers camp run by Nepal. However, the UN refused to acknowledge any responsibility for causing the cholera outbreak. Readers of this case consider the role of global governance and accountability, especially in an environment with a weak nation state.

Quelch, J.A. & Norris, M. , 2014. Access Health CT: Marketing Affordable Care (Parts A & B) , Harvard Business Publishing. Available from Harvard Business Publishing Abstract At the close of open-enrollment in March of 2014, Kevin Counihan, CEO of Access Health CT, Connecticut's state health insurance exchange, stops to consider the success it has experienced so far and think about how to ensure its long-term sustainability.

Datar, S.M., Cyr, L. & Bowler, C.N. , 2018. Innovation at Insigne Health , Harvard Business Publishing: Harvard T.H. Chan School of Public Health case collection. Available from Harvard Business Publishing Abstract Insigne Health is a for-profit, integrated health insurer/health care provider whose leadership believes that by shifting members' focus from "sickness" to "well-being" it could increase the overall health of its insured population and decrease the resources it spends each year on delivering care. The case puts students in the role of design researcher charged with understanding the member segment about which Insigne Health leadership is most concerned: The "silent middle." This cohort represents 70% of membership and is "neither sick nor well." Without changes in a range of behaviors, these members may be quietly developing conditions that will evolve into costly chronic diseases. From interviews included in the case, students uncover insights into member behavior and, based on these insights, generate and develop concepts to help members change behaviors and lead healthier lives.

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How to present patient...

How to present patient cases

Related content
Peer review
Mary Ni Lochlainn , foundation year 2 doctor 1 ,
Ibrahim Balogun , healthcare of older people/stroke medicine consultant 1
1 East Kent Foundation Trust, UK

A guide on how to structure a case presentation

This article contains...

-History of presenting problem

-Medical and surgical history

-Drugs, including allergies to drugs

-Family history

-Social history

-Review of systems

-Findings on examination, including vital signs and observations

-Differential diagnosis/impression

-Investigations

-Management

Presenting patient cases is a key part of everyday clinical practice. A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical competence. 1

The purpose of a case presentation is to communicate your diagnostic reasoning to the listener, so that he or she has a clear picture of the patient’s condition and further management can be planned accordingly. 2 To give a high quality presentation you need to take a thorough history. Consultants make decisions about patient care based on information presented to them by junior members of the team, so the importance of accurately presenting your patient cannot be overemphasised.

As a medical student, you are likely to be asked to present in numerous settings. A formal case presentation may take place at a teaching session or even at a conference or scientific meeting. These presentations are usually thorough and have an accompanying PowerPoint presentation or poster. More often, case presentations take place on the wards or over the phone and tend to be brief, using only memory or short, handwritten notes as an aid.

Everyone has their own presenting style, and the context of the presentation will determine how much detail you need to put in. You should anticipate what information your senior colleagues will need to know about the patient’s history and the care he or she has received since admission, to enable them to make further management decisions. In this article, I use a fictitious case to show how you can structure case presentations, which can be adapted to different clinical and teaching settings (box 1).

Box 1: Structure for presenting patient cases

Presenting problem, history of presenting problem, medical and surgical history.

Drugs, including allergies to drugs

Family history

Social history, review of systems.

Findings on examination, including vital signs and observations

Differential diagnosis/impression

Investigations

Case: tom murphy.

You should start with a sentence that includes the patient’s name, sex (Mr/Ms), age, and presenting symptoms. In your presentation, you may want to include the patient’s main diagnosis if known—for example, “admitted with shortness of breath on a background of COPD [chronic obstructive pulmonary disease].” You should include any additional information that might give the presentation of symptoms further context, such as the patient’s profession, ethnic origin, recent travel, or chronic conditions.

“ Mr Tom Murphy is a 56 year old ex-smoker admitted with sudden onset central crushing chest pain that radiated down his left arm.”

In this section you should expand on the presenting problem. Use the SOCRATES mnemonic to help describe the pain (see box 2). If the patient has multiple problems, describe each in turn, covering one system at a time.

Box 2: SOCRATES—mnemonic for pain

Associations

Time course

Exacerbating/relieving factors

“ The pain started suddenly at 1 pm, when Mr Murphy was at his desk. The pain was dull in nature, and radiated down his left arm. He experienced shortness of breath and felt sweaty and clammy. His colleague phoned an ambulance. He rated the pain 9/10 in severity. In the ambulance he was given GTN [glyceryl trinitrate] spray under the tongue, which relieved the pain to 5/10. The pain lasted 30 minutes in total. No exacerbating factors were noted. Of note: Mr Murphy is an ex-smoker with a 20 pack year history”

Some patients have multiple comorbidities, and the most life threatening conditions should be mentioned first. They can also be categorised by organ system—for example, “has a long history of cardiovascular disease, having had a stroke, two TIAs [transient ischaemic attacks], and previous ACS [acute coronary syndrome].” For some conditions it can be worth stating whether a general practitioner or a specialist manages it, as this gives an indication of its severity.

In a surgical case, colleagues will be interested in exercise tolerance and any comorbidity that could affect the patient’s fitness for surgery and anaesthesia. If the patient has had any previous surgical procedures, mention whether there were any complications or reactions to anaesthesia.

“Mr Murphy has a history of type 2 diabetes, well controlled on metformin. He also has hypertension, managed with ramipril, and gout. Of note: he has no history of ischaemic heart disease (relevant negative) (see box 3).”

Box 3: Relevant negatives

Mention any relevant negatives that will help narrow down the differential diagnosis or could be important in the management of the patient, 3 such as any risk factors you know for the condition and any associations that you are aware of. For example, if the differential diagnosis includes a condition that you know can be hereditary, a relevant negative could be the lack of a family history. If the differential diagnosis includes cardiovascular disease, mention the cardiovascular risk factors such as body mass index, smoking, and high cholesterol.

Highlight any recent changes to the patient’s drugs because these could be a factor in the presenting problem. Mention any allergies to drugs or the patient’s non-compliance to a previously prescribed drug regimen.

To link the medical history and the drugs you might comment on them together, either here or in the medical history. “Mrs Walsh’s drugs include regular azathioprine for her rheumatoid arthritis.”Or, “His regular drugs are ramipril 5 mg once a day, metformin 1g three times a day, and allopurinol 200 mg once a day. He has no known drug allergies.”

If the family history is unrelated to the presenting problem, it is sufficient to say “no relevant family history noted.” For hereditary conditions more detail is needed.

“ Mr Murphy’s father experienced a fatal myocardial infarction aged 50.”

Social history should include the patient’s occupation; their smoking, alcohol, and illicit drug status; who they live with; their relationship status; and their sexual history, baseline mobility, and travel history. In an older patient, more detail is usually required, including whether or not they have carers, how often the carers help, and if they need to use walking aids.

“He works as an accountant and is an ex-smoker since five years ago with a 20 pack year history. He drinks about 14 units of alcohol a week. He denies any illicit drug use. He lives with his wife in a two storey house and is independent in all activities of daily living.”

Do not dwell on this section. If something comes up that is relevant to the presenting problem, it should be mentioned in the history of the presenting problem rather than here.

“Systems review showed long standing occasional lower back pain, responsive to paracetamol.”

Findings on examination

Initially, it can be useful to practise presenting the full examination to make sure you don’t leave anything out, but it is rare that you would need to present all the normal findings. Instead, focus on the most important main findings and any abnormalities.

“On examination the patient was comfortable at rest, heart sounds one and two were heard with no additional murmurs, heaves, or thrills. Jugular venous pressure was not raised. No peripheral oedema was noted and calves were soft and non-tender. Chest was clear on auscultation. Abdomen was soft and non-tender and normal bowel sounds were heard. GCS [Glasgow coma scale] was 15, pupils were equal and reactive to light [PEARL], cranial nerves 1-12 were intact, and he was moving all four limbs. Observations showed an early warning score of 1 for a tachycardia of 105 beats/ min. Blood pressure was 150/90 mm Hg, respiratory rate 18 breaths/min, saturations were 98% on room air, and he was apyrexial with a temperature of 36.8 ºC.”

Differential diagnoses

Mentioning one or two of the most likely diagnoses is sufficient. A useful phrase you can use is, “I would like to rule out,” especially when you suspect a more serious cause is in the differential diagnosis. “History and examination were in keeping with diverticular disease; however, I would like to rule out colorectal cancer in this patient.”

Remember common things are common, so try not to mention rare conditions first. Sometimes it is acceptable to report investigations you would do first, and then base your differential diagnosis on what the history and investigation findings tell you.

“My impression is acute coronary syndrome. The differential diagnosis includes other cardiovascular causes such as acute pericarditis, myocarditis, aortic stenosis, aortic dissection, and pulmonary embolism. Possible respiratory causes include pneumonia or pneumothorax. Gastrointestinal causes include oesophageal spasm, oesophagitis, gastro-oesophageal reflux disease, gastritis, cholecystitis, and acute pancreatitis. I would also consider a musculoskeletal cause for the pain.”

This section can include a summary of the investigations already performed and further investigations that you would like to request. “On the basis of these differentials, I would like to carry out the following investigations: 12 lead electrocardiography and blood tests, including full blood count, urea and electrolytes, clotting screen, troponin levels, lipid profile, and glycated haemoglobin levels. I would also book a chest radiograph and check the patient’s point of care blood glucose level.”

You should consider recommending investigations in a structured way, prioritising them by how long they take to perform and how easy it is to get them done and how long it takes for the results to come back. Put the quickest and easiest first: so bedside tests, electrocardiography, followed by blood tests, plain radiology, then special tests. You should always be able to explain why you would like to request a test. Mention the patient’s baseline test values if they are available, especially if the patient has a chronic condition—for example, give the patient’s creatinine levels if he or she has chronic kidney disease This shows the change over time and indicates the severity of the patient’s current condition.

“To further investigate these differentials, 12 lead electrocardiography was carried out, which showed ST segment depression in the anterior leads. Results of laboratory tests showed an initial troponin level of 85 µg/L, which increased to 1250 µg/L when repeated at six hours. Blood test results showed raised total cholesterol at 7.6 mmol /L and nil else. A chest radiograph showed clear lung fields. Blood glucose level was 6.3 mmol/L; a glycated haemoglobin test result is pending.”

Dependent on the case, you may need to describe the management plan so far or what further management you would recommend.“My management plan for this patient includes ACS [acute coronary syndrome] protocol, echocardiography, cardiology review, and treatment with high dose statins. If you are unsure what the management should be, you should say that you would discuss further with senior colleagues and the patient. At this point, check to see if there is a treatment escalation plan or a “do not attempt to resuscitate” order in place.

“Mr Murphy was given ACS protocol in the emergency department. An echocardiogram has been requested and he has been discussed with cardiology, who are going to come and see him. He has also been started on atorvastatin 80 mg nightly. Mr Murphy and his family are happy with this plan.”

The summary can be a concise recap of what you have presented beforehand or it can sometimes form a standalone presentation. Pick out salient points, such as positive findings—but also draw conclusions from what you highlight. Finish with a brief synopsis of the current situation (“currently pain free”) and next step (“awaiting cardiology review”). Do not trail off at the end, and state the diagnosis if you are confident you know what it is. If you are not sure what the diagnosis is then communicate this uncertainty and do not pretend to be more confident than you are. When possible, you should include the patient’s thoughts about the diagnosis, how they are feeling generally, and if they are happy with the management plan.

“In summary, Mr Murphy is a 56 year old man admitted with central crushing chest pain, radiating down his left arm, of 30 minutes’ duration. His cardiac risk factors include 20 pack year smoking history, positive family history, type 2 diabetes, and hypertension. Examination was normal other than tachycardia. However, 12 lead electrocardiography showed ST segment depression in the anterior leads and troponin rise from 85 to 250 µg/L. Acute coronary syndrome protocol was initiated and a diagnosis of NSTEMI [non-ST elevation myocardial infarction] was made. Mr Murphy is currently pain free and awaiting cardiology review.”

Originally published as: Student BMJ 2017;25:i4406

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed

↵ Green EH, Durning SJ, DeCherrie L, Fagan MJ, Sharpe B, Hershman W. Expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors. J Gen Intern Med 2009 ; 24 : 370 - 3 . doi:10.1007/s11606-008-0900-x pmid:19139965 . OpenUrl CrossRef PubMed Web of Science
↵ Olaitan A, Okunade O, Corne J. How to present clinical cases. Student BMJ 2010;18:c1539.
↵ Gaillard F. The secret art of relevant negatives, Radiopedia 2016; http://radiopaedia.org/blog/the-secret-art-of-relevant-negatives .

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Medical Case Study Example

Medical case studies are generally considered some of the most challenging types of academic writing assignments for several reasons: they require deep knowledge of various practices, theories and approaches; they are extremely time-consuming, since they require examining, studying and researching many materials; and they require use of specific medical terms, models, concepts and lexis.

Writing a medical case study is a serious task for any student. Therefore, when assigned to write a medical case study, a thorough preparation is in order, which includes getting thoroughly acquainted with basic standards, rules and recommendations for writing a good case study on a medical subject. Another good tip, for those struggling with their medical case study, is to review some medical case study examples written by professional writers, skilled and experienced in writing such papers.

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The following extract has been taken from a medical case study example on Communication Disorder. The main purpose of this medical case study example is to show the problem of learning disability and language delay in children. Moreover, this medical case study example highlights various therapy goals most commonly described by professionals working with children with learning disabilities.

SPEECH & HEARING CENTER

Communication Disorder. Learning Disability Therapy Goals

Case One Psychologists observe that unless a child develops appropriate play skills through interaction with peers and objects, their social development is significantly impaired. Based on this argument, the goal of the therapy is to enhance specific skills necessary for interacting with peers and objects in a playground environment.

Case Two The second case therapy is aimed to enhance a child’s ability to develop his or her speech. The therapist recognized the need to help the child develop his or her speech through the auditory model.

Case Three In case three, the therapist attempted to improve a child’s language modality. This being a non-fluent aphasia case, the clinician employed the melodic intonation therapy to help the child achieve the goal.

Case Four In the fourth case, the therapy is aimed at improving a child’s playing ability in a social setting. Since most mentally ill children exhibit different problems with interacting with peers, the imitation strategy was used in this case.

Case Five The therapy in this case is aimed at establishing what is required for intervention. In achieving this goal, the therapist sought to establish whether there were other contextual variables that facilitated the observed behaviors.

Materials: Books? Games? Toys? Homemade or Commercial Instruments? Games, books, toys, homemade or commercial instruments are vital tools that can be used to …

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Original research
Open access
Published: 09 November 2023

The holistic effects of medical cannabis compared to opioids on pain experience in Finnish patients with chronic pain

Jussi Jylkkä ORCID: orcid.org/0000-0002-0655-5977 1 ,
Aleksi Hupli 2 ,
Aleksandra Nikolaeva 3 ,
Sandra Alanen 1 ,
Anna Erika Back 1 ,
Sara Lindqvist 1 ,
Andreas Krabbe 1 ,
Maya Lavie-Ajayi 4 &
Oskari Kantonen 5

Journal of Cannabis Research volume 5 , Article number: 38 ( 2023 ) Cite this article

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Medical cannabis (MC) is increasingly used for chronic pain, but it is unclear how it aids in pain management. Previous literature suggests that MC could holistically alter the pain experience instead of only targeting pain intensity. However, this hypothesis has not been previously systematically tested.

A retrospective internet survey was used in a sample of Finnish chronic pain patients (40 MC users and 161 opioid users). The patients evaluated statements describing positive and negative phenomenological effects of the medicine. The two groups were propensity score matched to control for possible confounding factors.

Exploratory factor analysis revealed three experience factors: Negative Side Effects, Positive Holistic Effects, and Positive Emotional Effects. The MC group (matched n = 39) received higher scores than the opioid group (matched n = 39) in Positive Emotional Effects with large effect size (Rank-Biserial Correlation RBC = .71, p < .001), and in Holistic Positive Effects with medium effect size (RBC = .47, p < .001), with no difference in Negative Side Effects ( p = .13). MC and opioids were perceived as equally efficacious in reducing pain intensity. Ratings of individual statements were exploratively examined in a post hoc analysis.

MC and opioids were perceived to be equally efficacious in reducing pain intensity, but MC additionally positively affected broader pain-related factors such as emotion, functionality, and overall sense of wellbeing. This supports the hypothesis that MC alleviates pain through holistically altering the pain experience.

Chronic pain refers to pain that has pertained for at least three consecutive months. In the European Union, 19% of adults suffer from chronic pain that has lasted for more than six months (Breivik et al. 2006 ). In Finland, 35% of adults have suffered from pain of at least three months duration, and the prevalence of daily chronic pain is 14% (Mäntyselkä et al. 2003 ). Both opioids and medical cannabis (MC) are commonly used for pain alleviation (Schlag et al. 2021 ; Wertheimer et al. 2021 ). Opioids are known to efficiently alleviate pain both acutely and chronically (Meske et al. 2018 ), but they have several adverse side effects, some of them potentially fatal (Paul et al. 2021 ). While the side effects of MC are mainly non-severe (Deshpande et al. 2015 ; Ware et al. 2015 ), its efficacy is disputed and mechanisms of action lack clarity (Fisher et al. 2021 ; Häuser et al. 2018 ). These unclarities could stem from many reasons, including the great variety of cannabis based medical products and variants of cannabis plants (Russo & Marcu 2017 ; Schlag et al. 2021 ), as well as the complexity of the molecular targets of different cannabinoids (Mlost et al. 2020 ; Morales et al. 2017 ). Another possible reason for the inconsistencies in previous research is the complex effects of cannabis on the psyche, which is our focus in the present study.

Previous research has mainly focused on the analgesic effect of MC (i.e., its capacity to reduce pain intensity), but pain sensation is a multifaceted experience involving more than nociception (St. John Smith 2018 ). It is well-known that cannabis can alter the state of consciousness, but not much attention has been paid to the question whether this could constitute a part of the therapeutic effect of MC on pain. In a previous qualitative interview study of seriously and terminally ill patients in California (Chapkis 2007 ), the psychoactive effects of MC were associated with feelings of wellness, increased acceptance of the pain, being able to ignore the pain and do other things, uplifting of the spirit, increased focus, as well as psychological and spiritual insights. On the other hand, unwanted side-effects, such as disturbed memory processes, tolerance, and dependence were also reported. Another qualitative study with chronic pain patients from an Israeli pain clinic (Lavie-Ajayi & Shvartzman 2019 ) found that MC facilitated the development of a different bodily subjectivity, described as a “sigh of relief”, a sense of relaxation and serenity that allows the patients an opportunity to unload some of the tension experienced by the constant fight against the pain. In addition, the use of MC was also described by many patients as having a holistic effect that enabled them to function better in their daily lives, including increased ability to sleep, focus, and function (ibid.).

In addition to these qualitative studies, there is quantitative research supporting the notion that MC has therapeutically relevant positive effects beyond pain intensity per se. A systematic review of placebo-controlled studies on the effects of cannabis on acute experimentally induced pain in healthy participants found that cannabis did not affect perceived pain intensity, but instead made the pain feel less unpleasant and more tolerable (De Vita et al. 2018 ). Further, a cross-sectional study on chronic pain patients found that MC users experienced substantially less depression and anxiety than opioid users (Feingold et al. 2017 ), suggesting that MC may have therapeutic effects in chronic pain patients over and above reducing pain intensity. The use of MC in chronic pain has also been associated with improved physical and social functioning and overall quality of life (Haroutounian et al. 2016 ; Pritchett et al. 2022 ; Vigil et al. 2017 ), as well as improvements in mental health and anxiety (Safakish et al. 2020 ). On the neurocognitive level the pain-alleviating effects of MC have been associated with changes in connectivity between brain regions associated with emotional regulation and lower somatosensory areas, suggesting that cognitive-emotional modulation may mediate the effects of MC on pain (Weizman et al. 2018 ). There is also evidence that THC reduces the perceived unpleasantness of experimentally induced pain, correlated with amygdala activity and reduced sensory-limbic functional connectivity (Lee et al. 2013 ), leading these authors to conclude that the “dissociative” effects of THC are relevant to pain relief. Importantly, a recent naturalistic study utilizing data from 1,882 users of a medical cannabis treatment tracking app directly assessed the association between feeling “high” and experiencing therapeutic effects (Stith et al. 2023 ). Overall, feeling high was associated with symptom relief across most of the patient subgroups, including those who used MC for pain relief, but feeling high also predicted more negative side effects (ibid.).

The previous research thus supports the hypothesis that MC may exert its therapeutic effect on pain through altering the pain experience in a more holistic way than traditional analgesics. That is, in addition to having an antinociceptive effect (i.e., removing pain or lessening its intensity), MC may affect the pain experience more broadly, influencing factors such as mood and emotion, pain tolerance, functionality, and overall well-being. On this account, the consciousness-altering psychoactive effects of MC could be a part of its therapeutic mechanism, instead of merely negative side effects. This hypothesis has not, however, been systematically tested. In this preregistered retrospective survey study, we recruited Finnish chronic pain patients who use either opioids or MC for their pain (preregistration at https://osf.io/txaph ). We asked the patients to rate how they experienced the effects of the medicine (opioids or MC), using a questionnaire. The preregistered hypothesis was that whereas opioids mainly affect the intensity of the pain, MC affects the pain experience in a more holistic way, affecting factors such as functionality, emotion and mood, and mindfulness. Our focus was on the perceived effects of MC, while the opioid group mainly served as controls. Neither MC nor opioids are first-line treatments for chronic pain, but both are commonly used when other treatments fail to provide sufficient pain relief. This could render the opioid and MC users similar in relevant background characteristics such as severity of pain and the underlying diagnosis, enabling better control of confounding factors.

Materials and methods

A cross-sectional survey study was employed on Finnish patients suffering from chronic pain who used MC or opioids for pain management. We devised a set of 45 experience questions to assess the overall perceived effects of the medicine, inspired both by the previous qualitative studies (Chapkis 2007 ; Lavie-Ajayi & Shvartzman 2019 ) as well as previous questionnaires such as the Brief Pain Inventory (Cleeland & Ryan 1994 ) and the Five Facet Mindfulness Questionnaire (Baer et al. 2006 ). The questions included items tapping on emotional factors such as “The medicine makes me more relaxed” or “improves my mood”; functional aspects such as “helps me to take care of myself” or “enables me to do the things I like”; mindfulness-related questions such as “enables me to feel the pain without reacting to it”, as well as holistic factors such as “has enabled me to gain a sense of normality in my life” or “has improved my life quality”. All the questions were answered on a seven-point Likert scale, where 1 indicates “Completely of the opposite opinion” and 7 “Completely of the same opinion”. The points were labeled, the midpoint (4) as “Neither of the opposite nor the same opinion”. All the questions are listed in Appendix A .

Information about the pain condition was gathered with the Chronic Pain Questionnaire (Pfizer 2021 ); psychiatric conditions were probed with the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult (Bravo et al. 2018 ); and severity of dependence was assessed with the Severity of Dependence Scale (Rush et al. 2003 ). The diagnosis underlying the pain condition was assessed with a multiple-choice question and the answers were recoded based on the open reports about the type of pain as well as the reported ICD-10 codes into the following categories: 1) Chronic musculoskeletal pain; 2) Chronic neuropathic pain; 3) Other specified chronic pain (e.g., fibromyalgia and type I complex regional pain syndrome, CRPS) or chronic pain of unknown etiology; 4) Chronic cancer-related pain; 5) Chronic visceral pain; and 6) Chronic headache or orofacial pain.

Opioid and cannabis use was probed by asking whether the patient uses these substances for pain management (yes / no), what is the weekly use frequency, average dose, type of the medicine, whether they had used the medicine during the last week, and prescription status (yes / never / discontinued). The options for the type of opioid were “weak (e.g., codeine, tramadol)”, “medium (e.g., burprenorphine)”, and “strong (e.g., fentanyl, hydromorphone, methadone, morphine, oxycodone)”. For MC, the options were “Bedrocan”, “Bediol”, “Sativex”, “Don’t know”, and “Other, please specify (e.g., what variety)”. Additionally, in the case of MC, the THC/CBD content was probed with the options “Balanced (50/50)”, “THC dominant”, “CBD dominant”, and “Don’t know”. The whole questionnaire is included as Appendix B .

The survey was distributed through email lists of Finnish chronic pain patient organizations, the Finnish Medical Cannabis Association, social media (e.g., Twitter and Facebook), as well as with flyers spread to the local smartshops selling cannabis-related equipment. The survey link led to a landing page including information about the study and eligibility criteria, which was that the patient suffers from chronic pain and uses opioids or medical cannabis to treat it. The eligibility was checked by examining the responses to the survey questions about pain duration (minimum three months), description of the pain diagnosis and symptomology, and types of medication used to treat it. Recreational users of cannabis or opioids and those who use the substances to treat other types of symptoms than chronic pain were explicitly asked not to partake in the study. To determine how to sum up the experience questions, we utilized exploratory factor analysis (EFA), following the recommendations of Worthington & Whitaker ( 2016 ) and Howard ( 2016 ). We used exploratory factor analysis and principal axis factoring (PAF) and the rotation method Promax (with kappa = 4) which allows for correlated factors. Problematic items were deleted following the 0.40—0.30—0.20 rule: an item should have at least 0.40 loading on the primary factor, max 0.30 loading on any secondary factors (i.e., “cross-loading”), and minimum difference between the primary and secondary loadings should be 0.20 (Howard 2016 ).

To account for background characteristics that may confound the results, we used propensity score matching (PSM) (for a general introduction, see Harder et al. 2010 ) on the following covariates: age, gender, type of pain, duration of pain, diagnosis (yes/no), as well as income and education level. Psychiatric variables such as anxiety and depression were not used as covariates, as they could be affected by the treatment (Feingold et al. 2017 ). The matching was conducted with the Matchit package (Ho et al. 2011 ) under R version 4.2.2 (R Core Team 2021 ), using the nearest neighbor method with 1:1 matching and logistic regression.

The preregistered analyses method for group comparisons was t-tests, but Mann–Whitney U-tests were used instead due to normality violations. Multiple comparisons were corrected by Bonferroni correction. Rank-Biserial Correlation was used as a non-parametric estimate of standardized effect size. Additionally, to see whether there are interactions between the experience factors and group, repeated ANOVAs were used.

In addition to frequentist p-values, Bayes factors were calculated to estimate the strength of evidence for the alternative in contrast to the null hypothesis. The Bayes factor BF 10 indicates the likelihood of the observed data if the alternative hypothesis holds, in proportion to its likelihood if the null hypothesis is true. For example, if BF 10 = 3, the data is three times more likely if the alternative hypothesis H1 is true. The BF 10 is interpreted as follows: > 100 Extreme evidence for H1; 30 – 100 Very strong evidence for H1; 10 – 30 Strong evidence for H1; 3 – 10 Moderate evidence for H1; 1 – 3 Anecdotal evidence for H1; 1 No evidence. Values below one indicate evidence for the null hypothesis, for example BF10 = 1/4 indicates moderate evidence for the null hypothesis (Jeffreys 1961 ).

The study was approved by the ethical council for psychology and logopedics at Åbo Akademi University, Finland. The testing was conducted by using an anonymous online survey that was distributed through patient organizations, social media and other social networks (e.g., patient groups). No compensation was given for participation.

The participants ( N = 201) were divided into two groups, MC users ( n = 40) and opioid users ( n = 161), based on which medicine they selected for evaluation in the experience questions. In the MC group, 18 (45%) reported also using opioids for their pain, and in the opioid group seven (4.3%) reported also using MC for their pain. Of the MC users, 29 (73%) reported having used MC during the last week, and in the opioid group 149 (93%) had used opioids during the last week. Moreover, of the MC users, 12 (30%) reported having used opioids during the last week, and of the opioid users two (1.2%) reported having used MC during the last week. In the opioid group 157 (99%) had an active prescription for the medicine and only one person had a discontinued prescription (prescription information was missing from three participants). By contrast, in the MC group only 10/40 (25%) had an active prescription, 11/40 (27.5%) had a discontinued prescription, and 17/40 (42.5%) had never had a prescription (prescription information was missing from two participants). We included in the study even the MC patients without prescription, given the substantial practical difficulties in getting prescription for MC in Finland (see Discussion ). In the MC group, 37/40 (93%) had a diagnosis and in the opioid group 159/161 (99%); this difference was significant in frequentist analyses but not supported by the Bayesian analysis (cross-tabulation BF 10 = 1/1.6, χ 2 = 5.17, p = 0.023). Demographic information and pain type with tests of group differences are described in Table 1 .

In the opioid group, 77 (48%) reported using a weak opioid (e.g., codeine or tramadol), 32 (20%) used a medium strength opioid (e.g., buprenorphine), and 50 (31%) used strong opioids (e.g., fentanyl or oxycodone), and data was missing for 2 cases. 149 (93%) reported using opioids within the last week, and total lifetime duration of opioid use was on average 7.12 years (SD = 6.28). Opioids were used in this group on average 9.50 times a week (SD = 6.59). However, weekly use data may not be reliable, as several patients reported using the medicine “continuously” (e.g., as transdermal patch) and these cases were coded as “7 times a week”. The average Morphine Equivalent Dose (MED) was 41.34 mg (SD = 37.67, range = 2 – 210), however missingness was n = 61 due to limited details about the type of opioid and use frequency which made it impossible to reliably calculate the MED for these participants.

In the MC group, 18 (45%) reported using Bedrocan, 1 (2.5%) used Bediol, 9 (22.5%) used some other type of specified cannabis flower, and 10 (25%) reported that they did not know the type of the cannabis they used. 29 (73%) had used MC during the last week. As to the ratio of THC and CBD, 24 (60%) reported that their medicine was THC-dominant, 7 (18%) reported balanced, and 2 (5%) reported CBD-dominant, whereas 5 (13%) did not know this information. Lifetime duration of MC use was on average 7.46 years (SD = 5.87) and average weekly use was 19.76 times (SD = 19.36). Average single dose was 0.65 g (SD = 1.01; range 0.01—5 g). As a method of use, 16 (40%) reported vaporizing, 12 (30%) reported smoking, 6 (15%) reported eating, and 4 (10%) reported “other” (e.g., tea, oil, or combined methods).

Factor analysis of the pain experience questions

The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy was excellent (0.93) and Bartlett’s test of sphericity was passed (χ 2 = 7519, df = 990, p < 0.001). Based on the scree plot, four factors were extracted. Before proceeding in the analysis, we examined the factor structure for face validity. The fourth factor included only two items (i.e., item 34, “The medicine causes hallucinations” and item 36, “The medicine makes me paranoid”) and was thus omitted. A three-factor analysis was then run without these two questions and the model explained 56% of the variance. Next, 13 problematic items were deleted due to violating the 0.40—0.30—0.20 rule (see Method ). Reliabilities in terms of Cronbach’s alphas were 0.93, 0.87, and 0.90 for the three factors respectively, indicating good-to-excellent reliability. The final 30 items and their factor loadings are presented in Table 2 .

We determined that the first factor (13 items) included negative side effects, including cognitive disturbances, emotional problems, as well as functional and somatic problems. This factor was titled “Negative Side Effects”. The second factor (7 items) mainly consisted of positive emotional effects and was titled “Positive Emotional Effects”. The third factor (10 items) consisted of a broader range of positive effects: The factor was driven by the items 9 and 8 about pain intensity and pain tolerance, but also consisted of holistic and functional items such as “Focus on other things” (item 11), “Improves life quality” (item 4), “Regain normality” (item 2), “Regain control” (item 5), “Take care of myself” (item 15), and “Attention to sensation” (item 12) (see Table 2 ). This factor was titled “Positive Holistic Effects”. The questions were averaged to gain factor scores.

Group comparisons

Before comparing the perceived effects of the medicine between the groups, matching was conducted for the relevant covariates (see Methods ). Data was missing about the duration of pain for ten participants (one in MC group and nine in the opioid group) and was imputed by the respective group means. Moreover, education data was missing from six participants in the opioid group and was imputed with the respective group mode two (corresponding to vocational school). We removed cases that reported as gender “other” or did not disclose this information (five in the opioid group and one in the MC group) due to an unreliably small number of observations. The matched data ( n = 39 in both groups) showed overall better balance than the unmatched sample, although some of the covariates were still above the recommended threshold value of 0.1 (see Fig. 1 ) (Stuart, Lee, & Leacy 2013 ). However, since no matching method yielded perfect balance and all the standardized mean differences for individual predictors were < 0.2, we proceeded to the main analysis.

Comparison of the matched vs. non-matched groups on the covariates. Although no ideal match was attained on all covariates, the match between the groups was substantially improved. Note : The standardized mean difference (SMD) indicates the extent to which the groups differ on a given covariate; smaller values are desired. The highlighted vertical line at .1 indicates the recommended maximum SMD. For information regarding how the background variables were assessed, see Table 1

The groups ( n = 39 each) were compared regarding their perceived effects of the medicine (MC or opioids) using the averaged factor scores. In terms of Bonferroni-corrected p-value, the MC group showed higher scores on Positive Emotional and Holistic Effects, but no difference in Negative Effects. This was supported by the Bayes Factor, indicating decisive evidence (BF 10 > 100) for more Positive Emotional Effects in the MC group, strong evidence (BF 10 > 10) for more Positive Holistic Effects in the MC group, but only anecdotal evidence (BF 10 < 3) of less Negative Side Effects in the MC group. The standardized effect size was large (0.71) for Positive Emotional and medium (0.47) for Positive Holistic. The results are summarized in Table 3 and Fig. 2 . Regarding the perceived efficacy of MC and opioids in reducing pain intensity, the average rating to the intensity-related items 9 and 10 was 5.91 (SD = 0.87) in the MC group and 5.39 (SD = 1.31) in the opioid group (range from 1 to 7), with no group difference (W = 586.50, p = 0.078, BF 10 = 1.19).

Raincloud plots of the group differences in the three factor scores, indicating most pronounced differences in Positive emotional effects, with higher ratings in the medical cannabis (MC) group. Note : The range in each factor is from 1 to 7, calculated as average to the respective experience questions which were rated on a 7-point Likert scale from “Completely of the opposite opinion” to “Completely of the same opinion”

As an additional group comparison, we examined if there is group difference in the average rating to the items 34 and 36 tapping on psychotic symptoms which were omitted from the factor analysis (see above). No group difference was observed (W = 657.00, BF 10 = 0.39, p = 0.15).

To see whether the group difference was larger for Positive Emotional Effects than for Positive Holistic Effects, we ran repeated measures ANOVA with the positive effect type (Emotional vs. Holistic) as the repeated factor, which showed an interaction with group and the factor type (F = 35.39, p = 7.74E-8, BF incl > 100). That is, the group difference was larger for Positive Emotional Effects than for Positive Holistic Effects. Finally, to get a deeper insight into the experienced differences between the two medications, we conducted a non-planned analysis of the differences between the matched groups in ratings to all the questions from the final factor solution, summarized as a forest plot in Fig. 3 . All items with means and standard deviations for the matched groups are summarized in Table 4 .

Explorative between-group comparisons of all the variables included in the final factor model, ordered by standardized effect size (Rank Biserial Correlation) from largest to smallest. Note : Larger effect size indicates higher rating in the medical cannabis group. Full item descriptions as well as group means and standard deviations for all the items can be found in Table 4 . Items where the confidence interval does not overlap with the vertical line can be considered as significant

It could be argued that recent opioid use in the MC group and recent MC use in the opioid group is a confounding factor in the analysis. Thus, a post hoc analysis was run to investigate whether the main group effects remain after excluding those in the groups who had used the other medication (i.e., MC in the opioid group or opioids in the MC group) during the last week. Two in the opioid group and 12 in the MC group were thus excluded, resulting in sample sizes of n = 37 and n = 27, respectively. In line with the main analysis, this comparison showed that the two groups did not differ in terms of negative side effects (W = 584, BF 10 = 0.58, p B = 0.77), but that the MC group showed higher ratings on the factors Positive Emotional (W = 135, BF 10 = 542, p B = 2.11E-06) and Positive Holistic (W = 281, BF 10 = 12, p B = 0.006).

Previous research indicates that MC may exert its therapeutic effect on pain through altering the pain experience holistically. That is, in addition to reducing pain intensity, MC may positively affect pain-related factors such as emotion and mood, functionality, and overall sense of well-being. By contrast, we hypothesized that the effect of opioids on pain is narrower, mainly targeting its intensity. We tested this hypothesis quantitatively in a survey study by assessing the perceived effects of MC or opioids in a group of Finnish chronic pain patients.

The main group comparison, based on the factor scores of the experience questions, indicated that MC and opioids did not differ in Negative Side Effects, but the effects of MC were rated as more positive in terms of the factors Positive Emotional and Positive Holistic Effects. Both MC and opioids were perceived to reduce pain intensity equally well. The group differences support the hypothesis that the effects of MC on pain are more holistic than those of opioids. The findings are in line with the previous qualitative research in support of the holistic positive effects of MC on pain (Chapkis 2007 ; Lavie-Ajayi & Shvartzman 2019 ). Moreover, the results corroborate previous data that MC alleviates pain-related negative emotion and increases pain tolerance (De Vita et al. 2018 ; Lee et al. 2013 ; Weizman et al. 2018 ), as well as findings that MC improves physical and social functionality and overall quality of life (Haroutounian et al. 2016 ; Pritchett et al. 2022 ).

The group differences were further examined by looking at the individual items exploratively (Fig. 3 ). The strongest group differences were, in order or magnitude, for relaxation, improved sleep, improved mood, and being able to feel pain without reacting to it. These items could reflect a broad range of cognitive-emotional processes. First, relaxation can be defined as relative absence of anxiety and physiological tension, manifested as calmness, peacefulness, and being at ease and has been associated with therapeutic benefits in pain management (Kwekkeboom & Gretarsdottir 2006 ). Second, pain is commonly associated with sleep disturbances, and sleep disturbance in turn can lead to worsening of pain and mood problems (Herrero Babiloni et al. 2020 ). Thus, sleep is a central node in the holistic network of pain-related experience factors. Third, mood disorders and pain frequently go together, and through acutely improving mood, MC could also decrease the unpleasantness of the pain sensation (cf. Tang et al. 2008 ). Fourth, being able to feel pain without reacting to it could be related to mindfulness processes such as detachment from the pain and pain acceptance, shown to be effective in pain management (Reiner, Tibi, & Lipsitz 2013 ).

It is noteworthy that the participants perceived MC and opioids as equally effective in reducing pain intensity. Given that opioids are known to be effective analgesics (Meske et al. 2018 ), this suggests that MC was perceived to have an analgesic effect, in addition to holistically altering the pain experience. This is in line with some previous reviews and meta analyses (Aviram & Samuelly-Leichtag 2017 ; Johal et al. 2020 ; Whiting et al. 2015 ), but inconsistent with others (Fisher et al. 2021 ; Gedin et al. 2022 ). These inconsistencies could stem from the wide range of cannabis-based medicines examined in previous research. It is possible that whole-plant cannabis flower, which was predominantly used by the patients in the present study, is more effective on pain intensity than isolated or synthetic cannabinoids. To illustrate, in the review of Fisher et al. ( 2021 ), only five of the 37 included studies examined cannabis flower, all with significant positive effects. Likewise, in Gedin et al. ( 2022 ) only six of the 20 studies that were included in the review dealt with whole plant-based products, all superior to placebo. By contrast, in both studies, the results concerning isolated and synthetic cannabinoids were mixed. Thus, the present results contribute to the cumulating evidence that whole-plant cannabis flower may be an effective analgesic.

In sum, the results lend support to the notion that the psychoactive effects of MC are relevant to its therapeutic effect on pain, in line with suggestions in previous literature (Chapkis 2007 ; Lavie-Ajayi & Shvartzman 2019 ; Lee et al. 2013 ; Stith et al. 2023 ). However, by “psychoactive” in this case we do not mean something that produces an altered state of consciousness in the sense of distorting one’s perception of reality and cognitive processes (Revonsuo et al. 2009 ), but instead something that holistically alters consciousness to a more positive direction, or towards “normality”. There were no indications that MC, despite its holistic effects on consciousness, was experienced to distort cognitive processes, but instead was perceived to improve memory, focus, and clarity of thought (see items 28–33 and 35, Table 4 ). This is in line with previous findings from a longitudinal study where MC use was associated with improved neurocognitive performance (Sagar et al. 2021 ). The results of the present study underline that the psychoactive effects of MC can be therapeutically positive and have beneficial effects on mood and functioning. However, this conclusion would require more robust testing, ideally in randomized controlled trials (RCT).

Limitations

A central limitation of the present survey study pertains to the special status of MC in Finland. Although legal in principle, prescription for MC is very difficult to attain. Medical cannabis prescription rates have decreased in Finland from about 370 in 2017 to 240 in 2020 and to around 160 in 2021 (Harmaala 2022 ; Honkasalo 2022 ; Vihervaara & Hupli 2021 ). In the first half of 2022 there were less than 50 prescriptions (Harmaala 2022 ). For these reasons, we decided already in the preregistration to include in the study even those MC patients without prescription. This could increase the risk of recreational users participating in the survey. However, to control for this risk, we probed extensively about the patients’ medical background and the results indicated that the groups mainly did not differ in the severity and type of their pain condition.

Another risk related to the special status of MC in Finland is that, due to the negative perceptions about MC of medical doctors and authorities as well as severe difficulties in receiving a MC prescription, the patients may exaggerate the benefits of MC. However, systematic exaggeration of the benefits of MC would arguably also lead to underrating negative side effects, which was not the case here. Moreover, there was a differential effect in the two positive factors, supported by the ANOVA analysis, with the group difference being larger for the emotional factor than for the holistic factor. It is unlikely that this interaction effect would be due to systematic exaggeration of positive effects.

The small sample size is an obvious limitation of the present study and is mainly due to the very small MC population in Finland. This limits the generalizability and reliability of the results and motivates replication in a larger, independent sample in a country where the MC population is larger. However, it can be argued that the present sample is relatively representative of the larger population of chronic pain patients that use MC to manage the pain. For example, in a study on US chronic pain MC patients ( N = 984) (Piper et al. 2017 ), the patients were 53% female, on average 49 years old, mainly had a vocational degree (38%), and mainly reported back/neck pain (91%), followed by neuropathic pain (30%). Most of them used MC as smoked (46%), followed by vaporized (23%). To compare, in our sample the participants were predominantly male (70%), of 43 years of age, mainly had vocational degree, and mainly suffered from neuropathic pain (60%) or other type of pain (60%) (note that we did not focus on pain location as Piper et al.). In our study, vaporizing was the most popular consumption method (40%), followed by smoking (30%). In sum, the present sample corresponds to some degree to the larger population of MC users, but there are also differences, motivating the use of a larger and more representative sample in future studies on this topic. Regarding the presence of “illegal” MC users in the present study, it is noteworthy that a Danish study ( N = 3,021) focusing on medical use of cannabis (including pain) found that most of the participants (91%) had no prescription for the medicine, suggesting that this trend is common even in countries with legal medical cannabis (Kvamme et al. 2021 ).

Another limitation of the present study pertains to the experience questionnaire, which has not been previously validated. Although the present results indicate that it has good psychometric properties in terms of factor structure and reliability, the questionnaire should be tested for construct and convergent validity, which was not within the scope of the present paper.

In general, there are inherent limitations to survey studies, pertaining to factors such as insufficient control, non-experimental design, and possible confounding factors. On the other hand, survey studies on existing patient populations can also be considered as a more ecologically valid approach compared to RCTs (Schlag et al. 2022 ). Survey studies should not be seen as competing with RCTs, but instead the two approaches can be seen as mutually supportive. The present results highlight the importance of considering the holistic effects of MC on the pain experience also in RCT research.

The results of the present study support the hypothesis that the effects of MC on pain experience are more holistic than those of opioids. MC may alleviate pain through affecting a broad range of pain-related experience experiental factors such as relaxation, improved sleep and mood, being able not to react to the pain, as well as a sense of control. These holistic effects of MC could explain the inconsistencies in clinical trials, where focus has mainly been on pain intensity instead of broader pain phenomenology. The results highlight the importance of taking these holistic effects into account in treating patients with MC, considering them as part of the therapeutic process.

Availability of data and materials

The datasets generated and/or analyzed during the current study are available in the Open Science Framework repository, https://osf.io/8x5e6/ .

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Acknowledgements

The authors are deeply grateful to the Finnish patient organizations that enabled the data gathering.

This work has been supported by the Kone Foundation (grant number 202105363). The funder had no role in the design of the study, data collection and analysis, interpretation of data, or in writing the manuscript.

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Jussi Jylkkä, Sandra Alanen, Anna Erika Back, Sara Lindqvist & Andreas Krabbe

Emerging Technologies Lab, Faculty of Social Sciences, Tampere University, Tampere, Finland

Aleksi Hupli

Turku Brain and Mind Center, Faculty of Medicine, University of Turku, Turku, Finland

Aleksandra Nikolaeva

Gender Studies Program, Ben-Gurion University of the Negev, Be’er Sheva, Israel

Maya Lavie-Ajayi

Department of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, University of Turku, Turku, Finland

Oskari Kantonen

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Contributions

JJ conceptualized and coordinated the study, took part in preparing the materials and data gathering, analyzed the data and wrote the first draft of the manuscript. AH took part in data gathering and writing of the manuscript. AN, SA, AB, and SL took part in planning the experiment, preparing the materials, data gathering, analysis, and commented on the manuscript. AK took part in the analysis. ML-A took part in writing the manuscript. OK took part in planning the experiment, data gathering, analysis, and writing the manuscript.

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Correspondence to Jussi Jylkkä .

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Jylkkä, J., Hupli, A., Nikolaeva, A. et al. The holistic effects of medical cannabis compared to opioids on pain experience in Finnish patients with chronic pain. J Cannabis Res 5 , 38 (2023). https://doi.org/10.1186/s42238-023-00207-7

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DOI : https://doi.org/10.1186/s42238-023-00207-7

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