How to write a case report

July 19, 2021
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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).

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.

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.

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) abstract/introduction, 2) case history/description, 3) literature review, 4) discussion, 5) conclusions/recommendations(3).

  1. 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.

  • 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.

  •  Literature Review

The organised literature search, similar to that described for systematic reviews, is listed in the methodology section for case reports. A well-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.

  •  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.

  • Summary/Conclusions/Recommendations 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).

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

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.

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