Ten Steps to Writing an Effective Case Report (Part 1)

A Case Report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of a patient. Case Reports may contain a demographic profile of the patient but usually describes an unusual or novel occurrence.

Step 1: Identify the Category of Your Case Report

• An unexpected association between diseases or symptoms
• An unexpected event in the course of observing or treating a patient
• Findings that shed new light on the possible pathogenesis of a disease or an adverse effect
• Unique or rare features of a disease
• Unique therapeutic approaches
• A positional or quantitative variation of the anatomical structures

Step 2: Select an Appropriate Journal

Journal selection should be based on the type of your Case Report.

Example, unusual injury presentations are more likely to be accepted in journals such as Trauma, rather than more mainstream, general-interest journals such as British Medical Journal; this does not publish Case Reports but only Lesson of the Week.

Another important point with respect to journal selection is that it is extremely important to follow the basic format required by the journal. Your Case Report may be rejected because it does not conform to the standard format, no matter how good the content is. Therefore, formatting such as margins, spacing, figure numbering, and style of references (Vancouver, Harvard, etc.), all are important aspects.

Step 3: Structure Your Case Report According to the Journal Format

Example

A suggested outline of sections for a Case Report is listed below.

• Abstract/Summary
  – The abstract (also know as summary) is concise and directly addresses your research topic.
• Introduction
  – The introduction is a more detailed explanation stating the purpose of the study, uniqueness of the case, and how it contributes to the existing literature.
• Case Presentation
  – Correctly elaborate the medical condition and medical history of the patient in chronological order as stated below:
  
  • Patient’s Examination/Identification
  • Medical History
  • Analysis of test results
  • Appropriate plan and analysis

• Differential Diagnosis
  • Support for conditions considered
  • Support for additional investigations

• Pathophysiology
  – State the physiological processes associated with the  diagnosed disease or injury.
  
• Treatment/Patient Management
  – Describe the treatment plan, follow-up, and final diagnosis.
• Discussion
  – Summarize the key features of the study and discuss the experiences learnt. Write the discussion in the flow stated below:
  • Etiology
  • Epidemiology
  • Prevalence
  • Complications
  • Prognosis
  • Ethical Dilemmas (if any)
• Conclusion
  – Conclude the case report with summary points, depending on the journal’s specified format. You could give suggestions and recommendations to practitioners, researchers, etc. in this section. 
• References
  – Relevant to your case report and must be cited appropriately throughout the paper following citation guidelines of the journal.

Step 4: Start Writing

So, how do you begin?

A Case Report is a way of communicating information to the medical world about a rare or unreported feature, condition, complication, or intervention by publishing it in a medical journal. Decide whether your Case Report is publishable. This can be decided based on the following criteria:

Does your Case Report,

• Describe rare, perplexing, or novel diagnostic features of a diseased state?
• Report therapeutic challenges, controversies, or dilemmas?
• Describe a new surgical procedure?
• Report how a drug can enhance a surgical procedure?
• Report new medical errors or medication errors?
• Describe rare or novel adverse drug reactions?
• Describe a therapeutic failure or a lack of therapeutic efficacy?

You should also ensure that you adhere to the following points:

• Do an extensive literature search—PubMed, Medline, Ovid, Embase, and even search engines like Google will give you a vast amount of information related to your topic.
• Narrow down the search to your actual topic
• If this comes up with very few search results, it means (assuming your search method is correct) that the case is rare, and the report is therefore more likely to be published.

Step 5: Collect Information Related to the Case

• Use the patient’s notes to record the details of all the events in the patient’s care—that is, history, examination findings, results of investigations with dates, and operative findings, if any, together with the details of the actual interventions and follow-ups.
• Use copies—do not take the originals of radiographs, photographs, etc (they are the patient’s only records for future reference).
• Verify all patient data such as history and dates of examination with the patient again and make sure you have got the facts right.

In our next article, we will discuss the remaining five points.