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Writing a Case Report

Case reports are a valuable component of medical literature. They convey new and unusual information about a medical condition to other medical professionals, stimulating research and improvements in clinical practice that lead to better health outcomes. They can alert the medical community to emerging new diseases, and suggest improvements in diagnostic strategies.(1) 

Some preliminary advice: What is unusual about the subject you want to write about? Gather all relevant materials – notes, lab reports, surgical reports etc. – and use them to frame the message you want to convey to the medical community. Do not over-speculate, or speculate beyond your expertise. Focus on reporting interesting facts.(2)

Use the following checklist to help you as you write your case report (length: 1500 – 2500 words):

Abstract (succinctly describe in 100 – 250 words)(3)

• Introduction & Aim.
• Patient Case Presentation.
• Discussion.
• Conclusion.

Introduction(4)

• Describe the subject matter.
• State your report’s purpose.
• Provide engaging background information (historical and social context).
• Provide relevant definitions.
• Describe the strategy of the literature review and provide search terms.
• When did you search?
• Which database did you use? (Ensure breadth by using different databases)
• What search terms, and in what language did you use?
• Briefly describe similar cases from published literature (cite properly).
• Briefly (less than 3 paragraphs) introduce the patient case to the reader.

Patient Case Presentation (in narrative form)(5)

• Narrate the case:
  • Use a chronological order.
  • Indicate the effect of treatment, specifically the post-treatment, as well as current status of the patient.
  • Establish causal and temporal relationships.
• Describe the patient’s demographics and history:
  • State patient’s age, sex, height, weight, race and occupation.
  • Exclude identifiers such as date of birth and initials.
  • List the patient’s current illness.
  • List the patient’s medical history (Is this your first time at a hospital? Do you suffer from any illnesses/diseases? Etc.).
  • List the patient’s social history (Who else lives with you? Do you take drugs? If so, how much? When did you stop? Etc.)
• Provide patient’s relevant laboratory and diagnostic data:
  • Sometimes, it may be necessary to provide relevant laboratory data to determine the appropriate dosage regimes.
  • State any drug allergies the patient may have, listing the name of the drug, as well as the date and type of reaction. 
  • State any adverse drug reaction history, including dates of the reaction. 
  • Describe any relevant results from clinical examination.
  • State relevant laboratory values that support the case.
  • Provide the reference range for laboratory values that are not widely known or established.
  • List the completed diagnostic procedures that are pertinent and support the case.
  • Describe the essential results of the diagnostic procedures.
  • Provide diagrams or photographs that clarify the case.
  • Ask patient for permission to use his/her photographs, or follow institutional guidelines.
• Describe the patient’s medication history:
  • State that patient was asked for this history.
  • List the patient’s medication history before admission and throughout the case report.
  • State each drug’s brand or generic name, strength, dosage form, route, and dates of administration.
  • Verify the patient’s medication adherence.
• Describe the patient’s diet:
  • Provide the patient’s diet history, as food can interact with drugs.

Discussion(6)

• Compare and contrast the fine distinctions of the case report with published literature. Also, explain or justify the similarities and differences between them.
• Confirm the accuracy of the reported data.
• Establish a temporal, and causal relationship. 
• List any limitations of the case, explaining their relevance.
• Summarize the essential features of the case report.
• Explain why the case is unique.
• Draw recommendations and conclusions.

Conclusion (brief and one paragraph only)(7)

• Provide a justified conclusion.
• Provide evidence-based recommendations.
• Explain the impact of the report on one’s own practice.
• List opportunities or suggest possibilities for further research.

Consent:

• Obtain written consent from the patient or his family to publish the case report and to use the accompanying images.

Acknowledgments:(8)

• Thank those who directly helped you to prepare the case report.

References:(9)

• Cite only references that are actually used to write the report.
• Critically assess references cited.
  
  

You can access, for free, hundreds of professional case reports at http://jmedicalcasereports.com/jmedicalcasereports/index

Note: IRB approval is generally not required for case reports because they are different from research. HIPAA (Health Insurance Portability and Accountability Act) regulations in the United States only require the author of the case report to obtain signed authorization from the patient or legal representative. To differentiate between a case report or research, please look at the guidelines in this link. As a general guideline, a case report involves 3 or fewer patients, and its results are not intended to be generalizable. Research, on the other hand, involves four or more patients, and involves a “systematic investigation intended to contribute to generalizable knowledge.” In other words, a case report is mainly intended to convey unusual medical occurrences and how they are treated, while research tests hypotheses by collecting and analyzing data in a rigorous manner.

Footnotes

Global Impact Lab

• Overview
• Frequently Asked Questions
• Importance of Global Health Research
• Advice From A Past Research Volunteer
• Recent Research Studies
• International Research Course
• Research Methodology Course
• Community Eye Health Research Database
• Community Eye Health Research Database Sorted By Date of Publication
• Writing Case Reports
• Publishing & Presenting Research