Helping Medical Students Write:
Genre Analysis of Medical Case Reports
Helán, Robert
Abstract
This study uses structural move analysis method of English for Specific Purposes (ESP) genre
research in order to examine medical case reports published in on-line medical journals. Specific
textual aspects deemed important for the investigation have been selected such as biomedical
rhetorical features and conventionalized lexis characteristic of this written medical discourse. The
study also explains the key differences between the three established genre research traditions. In
addition, important pedagogical applications are briefly discussed.
Key words: medical case reports, structural move analysis, genre research
Introduction
While medical research articles have received close attention in genre
research (e.g. Li, Ge, 2009; Nwogu, 1997; Skelton, Edwards, 2008), there has not
been an extended study of online published medical case reports (hereafter MCRs).
Being one of the oldest and most fundamental genres of medical writing (Dib, Kidd,
Saltmann, 2008), MCRs have only partially been investigated in diachronic studies
focusing on the development of medical writing in general (e.g., Salager-Meyer,
Defives, 1998; Taavitsainen, Pahta, 2000). Synchronically, two variant genres –
namely case histories and case presentations – have been analyzed from a critical
standpoint: the former by literary theorists (e.g., Charon, 1992; Montgomery Hunter,
1992) and the latter by a medical sociologist (Anspach, 1988).
This study offers additional insights into the characteristic features of written
medical discourse by analyzing the overall structure and distinctive linguistic
conventions of the genre of on-line MCRs.
Method of Analysis
The present study draws on and contributes to genre research and
methodology, as developed by the three genre research traditions: English for
Specific Purposes (Swales, 1990; Bhatia, 1993), New Rhetoric (Bawarshi, Reiff,
2010) and Systemic-Functional Linguistics (Halliday, Hasan, 1989). See table 1
below for a summary of the key distinctive characteristics of the three genre
movements. However, the present study employs the main analytical method of the
English for Specific Purposes (ESP) orientation – namely structural move analysis.
Structural move analysis was first introduced by Swales (1990, 2004) and
further elaborated on by Bhatia (1993) and Biber, Connor and Upton (2007). By
dividing texts into general organizational patterns, Swales (ibid.) demonstrated that
the texts contained recurring functional units which together contribute to the overall
communicative purpose of the genre. The outcome of his analysis was a three-move
schema for article introductions known as the Create a Research Space (CARS)
model.
Table 1: Main genre research traditions and their distinctive characteristics (Bawarshi, Reiff,
2010; Hyon, 1996)
English for Specific
Purposes
Systemic-Functional
Linguistics
New Rhetoric
Context · L2 – ESL/EFL
· tertiary education (EAP
classes)
· L1 and L2 (ESL)
· primary, secondary, and
immigrant adult education
· L1
· tertiary education, disciplines
and professions
Methods
of
Analysis
· structural move analysis (with
moves consisting of specific
steps)
· description of discourse
communities
· corpus-based studies
· register analysis of features of
social context (field, tenor, and
mode) that shape language
forms
· generic structure potential
· ethnographic methods:
participant observation,
interviews, document collection,
etc.
· methods allowing thick
descriptions of context
Genre
Definition
· communicative event
· consistency of communicative
purposes
· similarity in structure, style,
content and intended audience
· staged, goal-oriented social
process
· structural form that cultures use
in certain contexts to achieve
various purposes
· typification of social and
rhetorical action
· stabilized enough site of
social/ideological action
· fluidity and dynamics of
contexts and genres
Emphasis
on
· linguistic conventions
· organizational, stylistic and
grammatical features
· relationship between language
and functions in social settings
· social purposes that genres
fulfil within situational contexts
Genres
Analyzed
· research articles across
disciplines (and their specific
parts), university lectures,
dissertations, business letters,
fundraising letters, etc.
· factual writing – school genres
such as reports, procedures,
expositions, discussions,
recounts, explanations and
narratives
· genre sets and genre
systems in scientific
communities, tax accounting
firms, banks, university
under/graduate courses, etc
Genre-
Based
Pedagogy
· helping students control
linguistic conventions of
various genres
· flow chart analyses of genre
structure, gap filling of structural
slots, concordances, etc.
· detailed explicit genre
teaching methodology:
teaching and learning cycle –
context, modelling, negotiation,
construction
· LERN, AMES/AMEP
· tacit acquisition of genre
knowledge
· distributed learning
· activity theory
· focus on the process of writing
· WAC/WID/ECAC
Goals · guides and templates for
academic writing
· helping students become
successful writers of formal
academic texts
· student empowerment
· helping students in participating
effectively in the school
curriculum and the broader
community
· student awareness of social
action
· focus on unpacking complex
relations between text and
context
Major
Criticism
· too prescriptivist
· uncritical acceptance of current
academic genres
· no teaching methodology
· explicit genre teaching
· prescriptivism
· exclusion of
nonmainstream genres
· inconceivability of explicit
genre teaching
· uncritical acceptance of
professional genres
Main
Journals
· English for Specific Purposes
· Text
· Journal of English for Academic
Purposes
· Australian Review of Applied
Linguistics
· Annual Review of Applied
Linguistics
· Linguistics and Education
· Written Communication
· College Composition and
Communication
· Quarterly Journal of Speech
Medical Case Reports as Genre
The MCR can be defined as a medical recount of a pathological condition in a
single patient. Authors of MCRs are frequently clinicians who notice unusual,
interesting, or unique aspects of their patient‟s disease, treatment or adverse reaction
to the treatment. Multiple case reports of patients with similar conditions are usually
referred to as the medical case series.
MCRs have for a long time been regarded as inferior to the genre of medical
research articles, which are frequently based on randomized clinical trials. As MCRs
are mainly concerned with documenting the development of a pathological condition
and its treatment in a single patient, they are often perceived by the medical
community as being of relatively weak scientific evidence. On the other hand, there
are certain important features of MCRs that make them stand out. One of them is the
presentation of valuable information (e.g., comorbidities, patients‟ histories, doctors‟
reasoning in determining diagnoses) which is frequently lost in medical research
articles reporting results from clinical trials. In addition, from a pedagogical point of
view, MCRs offer an excellent opportunity for novice members of the medical
discourse community to publish reports of rare cases from their medical practice.
Recently, there has been a growing criticism of medical research which
regards randomized clinical trials as the only valid basis of medicine (Greenhalgh
2001:53). This criticism has been expressed by “a vocal pressure group within the
medical profession calling for the reinstatement of the humble case report as a useful
and valid contribution to medical science” (ibid.).
Historical Importance of Medical Case Reports
MCRs persist as the oldest and most canonical form of medical writing. The
genre dates back to Ancient Egypt (1600 B.C.), where medical accounts of individual
patients with oncological conditions were written on papyrus. These papyrus records
can be considered to be the first medical reports of cancer of the breast (Dib, Kidd,
Saltman, 2008). Other important MCRs describing the first cases of now well-known
diseases were, for instance, those of melanoma recounted in writing by Hippocrates
in the 5th
century B.C. or scurvy reported as early as 1500 B.C. in the Ebers papyrus
(Wang, Still, 2007). Examples of more recent significant MCRs include those of
Hodgkin‟s lymphoma described for the first time by Thomas Hodgkin to the MedicalChirurgical
Society of London in January 1832 (Dib, Kidd, Saltman, 2008) or a crucial
MCR written by Denborough et al and published in 1962, which solved the mystery of
malignant hyperthermia (an extremely high fever) and its etiology (Moore, 2007).
Smith (2008) summarizes succinctly the role that MCRs have played in medicine: “By
definition every new condition – whether it is AIDS, SARS, or the next emergent
disease – begins with a single case. ... (C)ase reports can provide definitive not just
indicative evidence.”
Data
Collected data for the present study comprise a corpus of 40 current MCRs
(published between 2007 and 2010) – 20 from the Cases Journal (CJ) and 20 from
the Journal of Medical Case Reports (JMCR). The main criteria adopted for the
selection of the samples were:
- peer-reviewed medical journals with open-access online publishing
- author‟s country of origin being an English-speaking country
- temporal, geographical, and disciplinary representativeness
Both journals offer open-access, peer-reviewed online medical case reports,
which can be freely downloaded from their websites6
. Authors of the selected MCRs
come from the following English-speaking countries7
: UK (16), USA (13), Australia
(5), New Zealand (2), Canada (2) and Ireland (2). As for the numbers of MCRs
selected per each year, see table 2.
Table 2: Number of MCRs selected per each year/journal
year 2007 2008 2009 2010 total
JMCR 4 6 6 4 20
CJ 08
7 10 3 20
total 4 13 16 7 40
The clinical disciplines9
represented in the corpus of 40 MCRs are surgery (6),
orthopedics (5), oncology (4), general medicine (3), infectious diseases (2),
respiratory medicine (2), emergency medicine (2), paediatrics (2), rheumatology (1),
urology (1), gastroenterology (1), neurology (1), ophthalmology (1), anaesthesiology
(1), cardiology (1), internal medicine (1), hepatology (1), nephrology (1),
endocrinology (1), intensive care (1), radiology (1), and psychiatry (1).
For the purpose of analyzing the above described corpus of 40 MCRs,
concordance software TextSTAT 2.510
was used. TextSTAT is a text analysis tool
which generates lists of word frequencies and concordances from either text files or
directly from the Internet. The corpus on which the present study is based has been
created from plain text files.
Move Analysis of Medical Case Reports
The following 13 moves have been identified in the corpus of 40 MCRs, based
on Swalesian (2004) CARS (Create a Research Space) model, Hoey‟s (2001) basic
problem-solution pattern, Nwogu‟s (1997) move analysis of medical research papers,
careful reading of the corpus material and the use of TextSTAT concordance
software (see the appendix for a move analysis applied to a specific MCR):
I. Introduction Sections
Move 1: ESTABLISHING A TERRITORY via contextualizing the report by providing
background information in the form of definitions and descriptions of the pathological
condition or diagnostic/investigative/operative procedure
Move 2: ESTABLISHING A NICHE via indicating a gap in clinical knowledge and the
relevance of the report by invoking its uniqueness and a lack or absence of reporting
Move 3: PRESENTING THE PRESENT WORK via announcing the present work
(optional)
II. Case Presentation Sections
6
http://medicalcasereports.com/ and http://www.casesjournal.com/content
7
The number of authors from a specific country is given in brackets.
8
Cases Journal started to be published in 2008, hence no case reports from 2007.
9
The number of reports from a specific discipline is given in brackets.
10
TextSTAT 2.5 can be downloaded from http://neon.niederlandistik.fu-berlin.de/en/textstatt/
Move 4: PRESENTING A PROBLEM via providing a clinical identification of the
patient by specifying the patient‟s demographics and history
Move 5: INVESTIGATING THE PROBLEM via summarizing the patient‟s diagnostic
data from significant examination findings and/or results of investigative procedures,
and determining the diagnosis.
Move 6: ADDRESSING THE PROBLEM via describing actions taken to treat the
patient by recapitulating any surgical or pharmaceutical interventions.
Move 7: EVALUATING THE OUTCOME via stating the success or failure of the
patient‟s treatment, having resulted either in the patient‟s survival and cure or death.
III. Discussion Sections
Move 8: PRESENTING BACKGROUND INFORMATION via describing (a specific
aspect of) the reported pathological condition, complication, special procedure, or
treatment and citing studies which aid in presenting this information
Move 9: REVIEWING LITERATURE PERTINENT TO THE CASE via contrasting and
comparing present and previous reports of similar cases or case series (or stating a
lack or absence thereof)
Move 10: REFERRING TO THE CASE via invoking relevant features of the reported
case in relation to the drawn implications
Move 11: DRAWING IMPLICATIONS via suggesting possible clinical, pedagogic, or
research implications and recommendations; and indicating limitations, cautions or
unanswered questions
IV. Conclusion Sections (optional)
Move 12: SUMMARIZING THE CASE via recapitulating the central features of the
medical case
Move 13: SUMMARIZING IMPLICATIONS via discussing the most important
implications and recommendations
Due to the limited space of this paper, only the most important features of
each section of the MCR will be discussed.
Ad I) The main function of the introduction sections of MCRs is to set the
scene for the subsequent presentation of the case. This is done especially by Moves
1 and 2. While the former contextualizes the report by providing background
information, the latter is realized through indicating a gap in clinical knowledge and
invoking uniqueness of the case and/or a lack or absence of its reporting.
Characteristic lexis used in Move 1 typically involves, inter alia, the following
expressions: common, frequently reported, and widely used as in “The most common
sites of gastrointestinal involvement are the stomach and colon.” (CJ 2/1/3). On the
other hand, Move 2 contains words such as unique, rare, and uncommon as in “SS is
a rare condition, with less than 100 cases described.” (CJ 1/1/348). Move 3 is an
optional move, occurring in 61,54% of all MCRs in the corpus. Self-mention is the
most distinctive feature of this move as in ”We report a case of „missed‟ ureteric
obstruction in a type II diabetic...” (CJ 1/1/192).
Ad II) One of the most characteristic features of the case presentation section
is its structure according to the problem-solution pattern (Hoey, 2001), which tends to
proceed as suggested in table 3. As can be seen from the table, negative evaluation
is repeated until positive evaluation and result – in the form of final diagnosis – are
achieved.
Table 3: Problem-solution pattern in the case presentation section (CJ 2/1/7176)
Problem-solution pattern The case presentation section of a given MCR
Situation (optional) A 30-year-old otherwise fit and healthy white British male was referred to our clinic by his
general practitioner with
Aspect of Situation
Requiring a Response
(i.e. Problem)
an ingrowing toenail of his right hallux from which he had suffered since childhood.
Response Examination of the foot revealed
Negative Evaluation no evidence of infection or cellulitis. The hallux nail was in-growing on both its edges, and
there was firm granulation tissue palpable at the lateral nail fold. The adjacent
interphalangeal joint was normal to examination.
Response A radiograph of the foot revealed
Negative Evaluation no evidence of osteomyelitis.
Response The patient underwent a total excision of the toe nail. At operation a small bony cutaneous
lump underlying the nail bed was excised in toto and sent for histopathological
examination. This revealed
Positive Evaluation and
Result
a well circumscribed dermal nodule of mature lamellar bone containing marrow spaces,
which represents osteoma cutis (Figure 1). At four week follow up the nail bed was healing
well and there was no evidence of any residual cutaneous lesions.
The case presentation section contains the most prototypical rhetorical
features, which have become an established convention of MCRs. In Move 4, the
patient is described as male/female, British/Hispanic, Caucasian/Asian/black, obese
with a certain age (a 40-year-old man). These pre-defined abstract categories, into
which each patient is classified, are used by physicians so as to render the patient in
biomedical terms. The data can then be used for statistical purposes such as the
occurrence of a certain disease among people from a specific age group, ethnic
background, or occupational sphere. Some other conventionalized collocations
include family history, medical history, the patient was admitted / referred to, positive
/ negative for etc. Another type of conventionalization is the use of factive (e.g., note,
observe, or find) and non-factive (e.g., deny or state) predicators. Predicators relating
to physicians tend to be factive11
, presenting the information in the case report as
objective and truthful, with the passive voice contributing to an even greater
objectivity, as in “It was found that the patient had a locally perforated splenic flexure
tumour...” (JMCR 3/1/9). Conversely, verbs used with patients tend to be non-
factive12
, reducing the patient‟s statements to a mere account, which is to be taken
with reservations, as in “She denied recent weight loss.” (JMCR 1/1/160). Here, the
physician leaves open the possibility that she might or might not have lost some
weight.
11
According to Crystal (1992, p. 175), the term factive verb refers to “a verb which takes a complement clause, and where the
speaker presupposes the truth of the proposition expressed in that clause“.
12
Non-factive verbs – also called “account markers” by Anspach (1988, p. 17) – “do not commit the speaker to the truth of the
proposition expressed in the complement clause” (Crystal ibid.).
The most interesting conventionalized linguistic features occurring in Move 5
refer to the presentation of the results from various diagnostic and investigative
procedures and tests (such as erythrocyte sedimentation rate [ESR],
electrocardiograph [ECG], computerized tomography [CT], or magnetic resonance
imaging [MRI]). Frequently, only their abbreviations are used as it is presumed that
they are well-known among the readers of the MCRs. In the case presentation
sections of MCRs, these procedures and tests are always expressed as agents
although they are performed by medical specialists. As Fleischman (2003, p. 479)
puts it: “... not only do the writers fail to mention the person(s) who performed the
diagnostic procedures, but they also omit mention of the often complex processes by
which angiograms and CT scans are interpreted. In treating medical technology as if
it were the agent, such formulations support a view of knowledge in which
instruments rather than people create the „data‟.” Verbs such as reveal, show,
confirm, or demonstrate are typically used as predicates to the medical technology as
in “Computed tomography (CT) showed distended loops of the small intestine.”
(JMCR 2/1/388).
Move 6 contains a multitude of instances of the agentless passive voice, which
contributes to the already depersonalized style of the case presentation sections.
The medical professionals behind the actions taken to treat and cure the patient are
completely left out of the report. The following example is a demonstration of the
overabundance of the agentless passive voice in the case presentation sections
(especially in Move 6, but the passive voice tends to appear throughout the section):
“... the patient was taken to theatre for... A posterolateral thoracotomy was performed
and the abscess collection was evacuated. A small perforation of the diaphragm was
also found and it was established that...” (JMCR 3/1/9).
Move 7 tends to include either a positive or negative evaluation. In the former,
expressions such as good clinical response, made a full recovery or no evidence of
(pathology) are used. The latter, negative evaluation, contains phrases denoting
failure of the treatment: e.g., symptoms returned, failed to improve or died. Instances
of both evaluations are the following: “Patient was seen in follow-up doing well and
without complaints.” (CJ 1/1/432); “Despite eventual clearance of her fungemia, the
patient died from multi-organ failure in June 2005.” (JMCR 3/1/7611).
Ad III) The discussion section seems to resemble the introduction section of
the MCR in that it also includes the presentation of background information and a
much more detailed literature review than in the introduction. The literature review
occurs in both Moves 8 and 9, but has slightly different functions. While in Move 8 it
helps to support the background information (as in Move 1), in Move 9 it invokes
similar cases to the one described in the report or emphasizes the lack or absence of
any related cases in the literature, thus emphasizing the rarity, novelty or uniqueness
of the reported case. Compare the following examples: “Bisphosphonates are the
cornerstones of treatment for steroid-induced osteoporosis. [3].” (CJ 2/1/7034) –
situating the case report in a particular research context, trend or tradition; ”McCune
and O‟Brien reported the induction of atrial fibrillation (AF) in a previously-well 35year-old
man [6].” (JMCR 4/1/76) – referring to other similar cases.
The most important move in this section is obviously Move 11, which fulfils the
section‟s main function, i.e. speculation. Speculation is frequently expressed via the
use of hedging devices such as modal verbs (especially may / might and can / could)
as in “This may suggest a hormonal predisposition to the condition.‖ (CJ 1/1/54).
Often, the move also contains advice or recommendation typically using the modal
verb should as in “Renal function should be assessed before general anaesthesia.”
(CJ 2/1/7593). Sometimes, implications of the case report are explicitly stated via the
use of verbs such as propose, speculate, hypothesize or exercise caution indicating
limitations of the report, cautions and unanswered questions, as in “We speculate
this was a result of tricuspid valve obstruction from the thrombus...” (JMCR
3/1/8582).
Ad IV) As only 30 out of 40 MCRs contained explicitly labelled conclusions
(75%), this section is not an integral part of the genre. Moreover, there were
approximately four sentences per conclusion, making it the lowest number of
sentences per section. Probably the most characteristic feature of this section, when
included in the MCR, is the reiteration of the uniqueness or novelty of the case, using
lexis such as novel, unique, or unusual, as in “This case has illustrated an unusual
presentation of a rare condition...” (JMCR 1/1/184)
Conclusion
Although MCRs have been regarded somewhat inferior to the medical
research paper based on clinical trials, the genre of MCRs is experiencing a
renaissance thanks to the birth of journals such as the Journal of Medical Case
Reports and several others, which focus exclusively on publishing original MCRs. In
addition, MCRs offer a significant opportunity for novice members of the medical
discourse community to publish reports of interesting cases. Unlike medical research
papers, MCRs tend to be shorter and relatively less complex. However, this does not
mean that they evade scientific precision.
As has been demonstrated, the language of MCRs is highly conventionalized,
consisting of collocational phrases not to be found anywhere else in written medical
discourse. The language of medicine in general and MCRs in particular has been
criticized for several reasons including: (1) a tendency to objectify the voice of the
medical technology which is placed in the subject position in the sentence (such as
CT scan demonstrated), (2) an absence of the agency behind the medical
procedures performed on the patient (such as biopsy was carried out), and (3) a
propensity to subjectify patient‟s accounts of their pathological conditions (such as
patient denied illicit drug use).
Typically, MCRs contain 11 moves if without conclusion sections or 13 moves
when conclusions are included in the reports. The moves tend to be recycled several
times when necessary (e.g., Move 1 or 2) while some moves are not used at all
(such as Move 3 or Move 12 and 13).
The most distinctive feature of the genre consists in its emphasis on the rarity,
uniqueness, novelty or uncommonness of the reported case, which is accentuated
especially in the introduction section of the report in Move 3. This appears to be the
reason for establishing a niche, a gap that is to be filled by the report.
The case presentation section differs from the other sections in that it does not
follow the established moves for medical research papers suggested by Nwogu
(1997). Instead, the structure of the section is based on Hoey‟s (2001) problemsolution
pattern, beginning with the presentation of the problem, proceeding with its
investigation and addressing, and ending with its evaluation.
Pedagogically, structural move analysis of MCRs enables students to practice
composing the genre according to the conventions established by the medical
discourse community. There are several possibilities how the analysis could be
incorporated into the teaching of medical writing at universities. The most basic
activity would involve giving students published MCRs in which they would identify
the above suggested moves. Alternatively, the teacher would indicate the moves in a
specific MCR without providing their descriptions and students would try to think of
the overall function of the moves.
A more advanced approach would incorporate concordance software (such as
TextSTAT 2.5) into the teaching of writing. By creating their own corpora through
collecting online case reports (or any other text-types) and uploading them into the
concordance software tool, students can immediately see the most frequent
collocations used in the genre. They can search the corpus for clarification of the
usage and terminology in the given genre. In addition, the corpus can help students
with fine-tuning any grammatical ambiguities such as the use of definite, indefinite or
zero articles.
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Cited Medical Case Reports from the Corpus
CJ 1/1/54 http://www.casesjournal.com/content/1/1/54
CJ 1/1/192 http://www.casesjournal.com/content/1/1/192
CJ 1/1/348 http://www.casesjournal.com/content/1/1/348
CJ 1/1/432 http://www.casesjournal.com/content/1/1/432
CJ 2/1/3 http://www.casesjournal.com/content/2/1/3
CJ 2/1/7034 http://www.casesjournal.com/content/2/1/7034
CJ 2/1/7176 http://www.casesjournal.com/content/2/1/7176
CJ 2/1/7593 http://www.casesjournal.com/content/2/1/7593
JMCR 1/1/160 http://www.jmedicalcasereports.com/content/1/1/160
JMCR 1/1/184 http://www.jmedicalcasereports.com/content/1/1/184
JMCR 2/1/388 http://www.jmedicalcasereports.com/content/2/1/388
JMCR 3/1/9 http://www.jmedicalcasereports.com/content/3/1/9
JMCR 3/1/7611 http://www.jmedicalcasereports.com/content/3/1/7611
JMCR 3/1/8582 http://www.jmedicalcasereports.com/content/3/1/8582
JMCR 4/1/76 http://www.jmedicalcasereports.com/content/4/1/76
Appendix – Structural analysis of a short MCR (CJ 2/1/7176) with highlighted lexis.
Introduction Section
MOVE 2 ESTABLISHING A NICHE Osteoma cutis is an excessively rare lesion which may be either primary or
secondary to neoplastic or inflammatory conditions [1].
MOVE 1 ESTABLISHING
A TERRITORY
Primary lesions are defined as such in the absence of a preceding skin lesion.
Secondary lesions are more common and are associated with scar tissue,
acne vulgaris, melanocytic naevi, and basal cell carcinoma. Osteoma cutis may
occur at any age and in either sex and has been reported on the hands [2],
MOVE 2 ESTABLISHING A NICHE but there are few reported cases of foot lesions [3].
MOVE 1 ESTABLISHING
A TERRITORY
It has been found to simulate verruca plantaris [4] as well as heel pain [3], but
lesions are far more frequently reported on the head and neck of white female
patients. There are a number of syndromes associated with osteoma cutis,
such as Albright's osteodystrophy [5], fibrodysplasia ossificans and progressive
osseous heteroplasia. The stimulus for osteoma formation is unknown.
Case Presentation Section
MOVE 4 PRESENTING A PROBLEM
A 30-year-old otherwise fit and healthy white British male was referred to our
clinic by his general practitioner with an ingrowing toenail of his right hallux from
which he had suffered since childhood.
MOVE 5 INVESTIGATING
THE PROBLEM
Examination of the foot revealed no evidence of infection or cellulitis. The
hallux nail was in-growing on both its edges, and there was firm granulation
tissue palpable at the lateral nail fold. The adjacent interphalangeal joint was
normal to examination. A radiograph of the foot revealed no evidence of
osteomyelitis.
MOVE 6 ADDRESSING
THE PROBLEM
The patient underwent a total excision of the toe nail. At operation a small
bony cutaneous lump underlying the nail bed was excised in toto and sent for
histopathological examination. This revealed a well circumscribed dermal
nodule of mature lamellar bone containing marrow spaces, which represents
osteoma cutis (Figure 1).
MOVE 7 EVALUATING
THE OUTCOME
At four week follow up the nail bed was healing well and there was no
evidence of any residual cutaneous lesions.
Discussion Section
MOVE 8 PRESENTING
BACKGROUND
INFORMATION
The incidence of in-growing toenail in the UK is estimated to be 10,000 new
cases per year [6]. In patients in whom it causes symptoms, it is often excised
and the nail bed cleared, however non operative management of in-growing
toenail is an accepted modality of management. When the nail punctures the
skin, granulation tissue is produced at the nail margin.
MOVE 11 DRAWING IMPLICATIONS What appears to be a primary ingrowing toe nail could sometimes be
secondary to other causes such as
MOVE 9 REVIEWING LITERATURE
PERTINENT TO THE CASE
soft tissue chondroma [7] osteochondroma [8], extraskeletal osteosarcoma [9]
as well as osteoma cutis;
MOVE 10 REFERRING TO THE CASE the latter which is rare is highlighted by this case report.
Kontakt: Mgr. Robert Helán
Centrum jazykového vzdělávání na Lékařské fakultě, Masarykova univerzita,
Kamenice 5, 625 00 Brno, Česká republika
E-mail: rhelan@med.muni.cz