Infectious Disease Case Report: Template, Example, and Generator

Template for an Infectious Disease Student Case Report

Sections in the order expected by most academic departments. The generator uses this exact structure; if your department requires a specific format, upload it as a template.

1. 1
   General patient data

   Age (not date of birth), gender, occupation/profession (omit organization name), date and time of admission, department, referral source/delivery method, referring facility diagnosis, admission diagnosis. Do not include full name, address, or document numbers: use "Patient N."

2. 2
   Complaints

   Chief complaints with details (localization, character, intensity, radiation, duration, triggers, and relieving factors) along with general symptoms; complaints upon admission and at the time of examination.

3. 3
   History of the present illness (Anamnesis morbi)

   Onset and progression, initial symptoms, clinical course, previous medical consultations, prior diagnostic tests and treatments before admission along with their efficacy, as well as the reason and circumstances of hospitalization.

4. 4
   Epidemiological history

   Detailed: contacts with infected individuals (who, when, diagnosis), exposure in foci, travel history (where, when), dietary history during the incubation period, water source, insect/animal bites, parenteral interventions, sexual contacts if indicated, vaccination history, occupational risk.

5. 5
   Past Medical History (Anamnesis vitae)
6. Brief biographical data, living conditions, and dietary habits

   Birthplace and upbringing, education, housing and living conditions, dietary habits, physical activity.

7. Occupational history

   Profession, length of service, working conditions, occupational hazards (without naming the organization).

8. Past medical history, surgeries, injuries

   Childhood infections, chronic diseases, surgeries, trauma, tuberculosis, viral hepatitis, STIs, blood transfusions (with reactions).

9. Bad habits

   Smoking (duration, pack-years), alcohol (frequency, quantity), illicit drug use.

10. Medication history

    Regular medications taken by the patient (name, dose, frequency).

11. Allergic history

    Drug, food, and household allergen intolerance; type of reaction.

12. Family history

    First-degree relatives' medical history (CVD, diabetes mellitus, oncology, tuberculosis, psychiatric conditions).

13. Obstetric and gynecological history

    For women: menarche, menstrual cycle characteristics, menopause, pregnancies/childbirth/abortions.

14. Insurance history

    Certificate of incapacity for work (duration), disability group.

15. 6
    Objective examination (Status praesens objectivus)
16. General physical examination

    General condition, level of consciousness, body position, physique, body type, height, body weight, BMI, body temperature; skin and visible mucous membranes, subcutaneous adipose tissue, edema, lymph nodes, muscles, bones, joints.

17. Respiratory system

    Chest inspection, respiratory rate, palpation (resistance, vocal fremitus), comparative and topographical percussion, auscultation (breath sounds, rales, crepitation, pleural friction rub), bronchophony, SpO2.

18. Cardiovascular system

    Inspection of the heart and neck vessels, apex beat, boundaries of relative cardiac dullness, auscultation (heart sounds, murmurs), pulse (rate, rhythm, volume, tension), blood pressure on both arms, peripheral arterial pulsation.

19. Digestive system

    Oral cavity, tongue, abdomen (inspection, superficial and deep palpation according to Obraztsov-Strazhesko, percussion, auscultation), liver dimensions according to Kurlov, gallbladder (symptoms), spleen, stool.

20. Urinary system

    Lumbar region inspection, kidney palpation, tapping sign (Pasternatsky's sign), urination, diuresis.

21. Endocrine system

    Thyroid gland (palpation, eye signs), subcutaneous fat distribution, secondary sexual characteristics.

22. Nervous system and sense organs

    Consciousness, orientation, sleep, memory, meningeal signs, focal symptoms, reflexes, vision, hearing.

23. 7
    Preliminary diagnosis and its rationale

    Identify syndromes based on complaints, history, and objective data, justify each; formulate a preliminary diagnosis.

24. 8
    Epidemiological Conclusion

    Suspected source, mechanism and route of transmission, timing of infection relative to the incubation period.

25. 9
    Examination plan

    Laboratory and instrumental studies and consultations with the purpose of each: according to clinical guidelines of the Russian Ministry of Health (mandatory and as indicated).

26. 10
    Results of laboratory and instrumental studies

    All available results with dates (in a table where appropriate) and interpretation: what is normal, what is abnormal, and what it means. Unperformed/missing studies should be listed as "no data".

27. 11
    Differential diagnosis

    At least 2–3 diseases with a similar presentation: for each, common features and differences used to rule it out (based on this patient's data).

28. 12
    Clinical diagnosis and its rationale

    Formulation according to the classification from clinical guidelines and ICD-10 (code): underlying disease, complications of the underlying disease, comorbid conditions; rationale for each component.

29. 13
    Etiology and pathogenesis

    Etiology and pathogenesis of the disease in general and applied to this patient (risk factors, mechanisms of syndrome development).

30. 14
    Treatment and its rationale

    Regimen, diet, non-pharmacological treatment, pharmacotherapy: drug (INN), dose, route, frequency, duration, and rationale with references to clinical guidelines; At the end: Latin prescriptions (Rp.: … D. S. …) for 2–3 main drugs. Etiotropic, pathogenetic, and symptomatic therapy should be listed separately.

31. 15
    Anti-epidemic measures

    Emergency notification, isolation, outbreak control measures, monitoring of contacts, discharge and clearance criteria.

32. 16
    Observation notes

    prescriptions).

33. 17
    Stage (discharge) epicrisis

    Briefly: patient, age, date of admission, presenting complaint, key examination results, clinical diagnosis, treatment provided and its effect, condition at the end of the follow-up period, recommendations. Discharge and clearance criteria.

34. 18
    Prognosis and recommendations

    Prognosis for life, for recovery, for working capacity (with justification); discharge recommendations and follow-up care according to clinical guidelines.

35. 19
    References

    formatted according to GOST R 7.0.100-2018.

How an Infectious Disease Case Report Differs from Others

An infectious disease case report centers around two questions: which pathogen caused the disease and where the patient contracted it. Therefore, the standard template is supplemented with an epidemiological history, epidemiological conclusion, a plan for infection control measures, and etiological confirmation of the diagnosis. Without these sections, the report will not be accepted, even if the clinical section is written well.

Epidemiological history

It is gathered specifically for the suspected infection, and the text must contain answers rather than a list of questions:

• contact with individuals experiencing similar symptoms at home, at work, or within a group/community;
• travel outside the region and abroad, especially to endemic areas;
• dietary intake in the days leading up to illness: what, where, whether others fell ill; source of drinking water;
• tick and mosquito bites, contact with animals and rodents, visits to forests and country houses (dachas);
• injections, blood transfusions, surgeries, dental treatment, tattoos, sexual contacts over the past 6 months if parenteral hepatitis and HIV infection are suspected;
• vaccination history and occupation: whether the patient belongs to a decreed occupational group.

What Departments Check Most Strictly

• Correlation with the day of illness. Temperature, rash, jaundice, and diarrhea must be described by the day of illness rather than the dates of hospitalization.
• Description of specific signs: for rash—elements, size, localization, day of onset, sequence of appearance, outcome; for diarrhea—frequency, volume, and character of stool.
• Diagnosis formulation: nosology, clinical form, variant, severity, complications, and method of laboratory confirmation (bacteriological, PCR, serological with specification of markers).
• Epidemiological conclusion: suspected source, route and factor of transmission, risk posed by the patient to others.
• Infection control measures: emergency notification, isolation, monitoring of contacts, focal disinfection, rules for discharge and follow-up (dispensary) monitoring.

Verify timelines and scope of measures for a specific infection against sanitary regulations (SanPiN 3.3686-21) and clinical guidelines: they vary depending on the infection.

Infectious Disease Case Report Example: Salmonellosis

A model example with a fictional patient. Patient N., 34 years old, admitted on the 2nd day of illness.

Epidemiological history

Eighteen hours before the onset of illness, she ate a salad with homemade mayonnaise made from raw chicken eggs. Out of four people who ate the salad, three fell ill with similar symptoms. She has not traveled outside the city within the past month and denies contact with infectious patients. She works as an accountant and does not belong to decreed occupational groups. She drinks bottled water.

Justification of the diagnosis

Acute onset with chills and fever up to 38.8 °C, followed by nausea, repeated vomiting, colicky pain in the epigastric and periumbilical regions, and abundant, loose, foul-smelling greenish stool up to 10 times a day. On examination, the tongue is dry and coated; the abdomen is soft and tender in the epigastric and periumbilical regions. Thirst, dry mucous membranes, heart rate 88 bpm, blood pressure 115/75 mm Hg, no convulsions.

The short incubation period, group character of the disease, and association with eating a raw-egg dish suggest salmonellosis. The combination of vomiting, epigastric and periumbilical pain, and enteritic stool corresponds to the gastroenteritic variant. Fever up to 39 °C, recurrent vomiting, and stool up to 10 times a day are characteristic of moderate severity. Thirst and dry mucous membranes without convulsions or hemodynamic disturbances correspond to grade I dehydration according to V. I. Pokrovsky's classification.

Clinical Diagnosis

Primary disease: Salmonellosis, gastrointestinal form, gastroenteritic variant, moderate severity.

Complication: Grade I dehydration.

ICD-10 code: A02.0 (Salmonella enteritis).

Prior to laboratory confirmation, the diagnosis remains provisional. Plan: bacteriological examination of stool and vomitus, stool PCR for enteric infection pathogens, serological testing using paired sera if necessary; complete blood count and urinalysis, electrolytes, creatinine, urea. Once results are obtained, the confirmation method is added to the diagnosis, e.g., "bacteriologically confirmed (Salmonella Enteritidis isolated)".

Epidemiological Conclusion and Measures

Suspected source of infection: chicken eggs; route of transmission: foodborne; factor of transmission: salad with homemade mayonnaise. Outbreak: group. Measures: emergency notification to the local Rospotrebnadzor authority (by phone within 2 hours, in writing within 12 hours), hospitalization based on clinical indications, identification and examination of other affected individuals, medical monitoring of contacts for 7 days, terminal disinfection in the focus.

Common Mistakes in Infectious Disease Case Reports

• Epidemiological history reduced to the phrase "denies contact with infectious patients," omitting diet, travel, bites, and parenteral interventions.
• The epidemiological conclusion is missing or does not follow from the gathered epidemiological history.
• Dynamics described by calendar dates rather than days of illness.
• Diagnosis lacks a clinical form, variant, severity grade, and method of laboratory confirmation.
• Diagnosis termed definitive prior to etiological confirmation.
• Rash described in a single word, lacking elements, localization, and day of onset.
• In intestinal infections, the degree of dehydration is not assessed.
• Infection control measures copied as a generic list without regard to the specific infection and the patient's occupation.
• Real patient data used in the identification section instead of anonymized data.

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