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How to Write a Case Report

Dr. Nancy Agnes, Head, Technical Operations, Pubrica, sales@pubrica.com

In brief

The preparation of case reports,using existing

recommendations and a random sample of recent

case reports, researchers developed a fill-in-the-

blanks worksheet for doctors to record specific

scientific findings. The case report worksheet,

which was initially designed to help family practice

residents to write case reports, can now be used by

physicians in any practice environment and

speciality to compile and report important, rare, or

newsworthy cases(1).

I. INTRODUCTION

Case reports are "scientific findings that have been

meticulously collected to serve as a useful

educational and research guide." Sir William Osier,

who was the author of a number of those

experimental findings, urged other doctors to do the

same "Always take care of something out of the

ordinary. Once you've made and documented the rare

or unique discovery, you can publish it." The

American Journal of Dermatopathology released a

case study (2).

A case study was searched using keywords for

different fields (e.g., obstetrics and gynaecology,

paediatrics, neurology and neurosurgery,

dermatology, general internal medicine, and family

medicine), and a random sample of reported case

reports was chosen.

II. WHAT KIND OF CASES SHOULD BE

REPORTED?

According to our analysis of published cases and

applicable standards, case reports should describe a

unique presentation, not just modifying a previously

mentioned case. A new or rare site for a previously

identified illness, for example, would not qualify as a

one-of-a-kind occurrence unless it is followed by

previously undocumented signs or necessitated an

especially time-consuming and expensive diagnosis

procedure.

In line with the tradition of published case reports,

most case reports concern specialities and

subspecialties that document unusual or exceptional

clinical experiences.

Table: 1

Characteristics of Cases Appropriate for

Publication in a Case Report

• Cases that contribute to a change in the

course of medical science.

• Cases that illustrate a new principle or

support or refute a current theory and thus

may stimulate research.

• Cases that present a therapeutic or

diagnostic observation that elucidates a

previously misunderstood clinical condition

or response.

• Cases that demonstrate an adverse response

to drug therapies or presumed cause–and–

effect presentations have not been detected

or reported.

III. THE COMPONENTS OF A CASE REPORT

Introduction, case presentation, and debate were

listed as the three main components of most recently

written material on how to write case reports."

We propose that these five parts be included in a case

study, based on all of the recommendations from

previously published guidance, as well as the

structural elements of many previously published

publications and our observations:1)

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abstract/introduction, 2) case history/description, 3)

literature review, 4) discussion, 5)

conclusions/recommendations(3).

IV. ABSTRACT

Abstracts and the title are an integral part of each

article's electronic bibliographic background in

databases like MEDLINE. Abstracts enable users

to easily scan an article's content to see if it is

interesting enough to warrant further reading.

Many publications that may be relevant to a

clinical condition may be overlooked if abstracts

are not used. We recommend including a brief

abstract that includes the clinical issue or

dilemma, an outline of the literature review, and

a brief statement summarising why this case is

rare and interesting in place of or in addition to

an introduction.

V. CASE HISTORY/REPORT

The case history or case report, which is usually

taken from chart notes and is a core component

of written case studies, is the second section. It

should start with a brief introduction to the

patient(s) and a description of the current

condition. Writers should provide details about

the medical evaluation and any test findings that

offer insight into the actual situation. Still, not all

test results should be provided, and "red

herrings" should be avoided because they are

likely to create complications for other doctors.

Include normal laboratory values for samples

that aren't as widely ordered.The purpose is to

include only the most important details to

highlight the case's most striking characteristics."

This section should include the original

diagnosis, care, and follow-up schedule. Tables,

flow charts, photographs, radiographs, and

figures can be included to elucidate the case.

VII. LITERATURE REVIEW

The organised literature search, similar to that

described for systematic reviews, is listed in the

methodology section for case reports. A well-

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constructed clinical query should be formulated,"

accompanied by an explanation of the index

words or MeSH headings used for the searches

such that anyone can replicate the search, such as

MeSH terms to address the clinical question,

"What are the potential causes of intractable

perioral rash in a 10-year-old boy?" "Dermatitis,

perioral," or "facial dermatoses," for example.

The literature review should be concise and

precise, intended to ensure the case's uniqueness

and provide a context for and role of the latest

evidence in the biomedical literature.

VIII. DISCUSSION

The most critical part of a case study is the

discussion area. This is where the writers explain

why knowledge is important. What about this

patient described your attention or was unusual?

Why is it necessary to write this down? What

would your colleagues discover? Notice that not

all subsets of the worksheet's topic section would

extend to all cases mentioned. Choose the places

that can better help elucidate the situation,

keeping in mind the two case reporting

watchwords: brevity and consistency. The bulk

of case studies reported in journals are fewer

than three journal pages long, and the vast

majority are one article or less.

IX.SUMMARY/CONCLUSIONS/RECOMME

NDATIONS SECTION

Finally, a short outline, conclusion, or

recommendations section—the take-home

message—should be included in the report. This

segment should include any lessons learned by

the practitioner when caring for this patient, such

as family, emotional, or quality-of-life lessons,

physician-patient contact barriers, or compliance

problems. "Why," for example, is a good

question to ask? "Now that I've had this training,

what will I do better next time?" or "May I make

any advice to other clinicians?" Study

recommendations can also be included. This

section should be short as well, usually no more

than one or two lines (4).

X. OVERCOMING BARRIERS TO WRITING

CASE REPORTS

A meeting of obstacles stands in the way

practitioners choose to write case reports or other

manuscripts for publication. The most significant

impediment is time. By guiding the clinician's

data collection, the case report worksheet will

help speed up preparing a case report (those

scientific observations that comprise a case

report). The comments and conclusions can be

easily formatted into a manuscript for

submission until they're done (5).

Table: 2

Partial Listing Of Primary Care Journals

That Accept and Publish Case Reports

Academic Emergency Medicine

American Family Physician

Archives of Family Medicine

Archives of Internal Medicine

Journal of Family Practice

Journal of the American Board of Family

Practice

Lancet

New England Journal of Medicine

XI. CONCLUSION

Case studies must be concise, provide new or

unique information, and organise and present

clinical findings in a regular, systematic manner.

Editors and editorial boards of primary care and

family medicine journals should establish basic

requirements for approving case reports (type of

article, volume, etc.) and include those criteria in

each journal's instructions for authors. The case

study worksheet provides a standardised guide to

writing case reports that can compile and arrange

experimental findings into engaging and

publishable case reports(6).

REFERENCES

1. Balon, Richard, and Eugene V. Beresin. "How to

write a case report." Roberts Academic Medicine

Handbook. Springer, Cham, 2020. 273-285.

2. Balon, Richard, and Eugene V. Beresin. "How to

write a case report." Roberts Academic Medicine

Handbook. Springer, Cham, 2020. 273-285.

3. Held, Philip, et al. "A case report of cognitive

processing therapy delivered over a single

week." Cognitive and behavioral practice 27.2

(2020): 126-135.

4. Acker, Michelle L., Juliann Nicholson, and Ellen

R. DeVoe. "Mothering very young children after

wartime deployment: A case report." Infant

mental health journal 41.3 (2020): 313-326.

5. Lindgreen, Adam, C. Anthony Di Benedetto, and

Michael B. Beverland. "How to write up case-

study methodology sections." (2020).

6. Morresey, P. R. "Response to correspondence

regarding 'How to write a clinical case

report'." Equine Veterinary Education 32.4

(2020): 224-224.