Step-By Step Guide to How to Write a Case Report

Case report definition states that in medical practice, it is a paper documenting the diagnosis, symptoms, applied treatment and case follow up of a patient. Case reports serve as the first-line piece of evidence in medical literature. The purpose of a case report is to communicate evidence-based information on clinical trials. Moreover, these reports assist medical professionals in outlining a hypothesis by sharing their clinical observations to support a scientific study.

Bio Med Central Research Notes and Journal of Medical Case Report, with different criteria, publish many case reports to facilitate medical practitioners. Many authors seek help from case databases, which is continually updating and providing free access to thousands of case studies from different publishers.

Functional Significance of Case Reports

As a time-honored tradition of the medical profession, the phenomenon of writing case reports has been a longtime practice of medical professionals. The practice began as personal communication among medical practitioners or anecdotal reporting regarding any unique medical case. Over the years, it evolved into a scholarly publication. Case reports have become a rapid dissemination of knowledge for a medical audience.

From diagnosis of a medical condition to scientific observations and the optimal course of treatment, a case report presents clinical insights, aiming to expand medical knowledge. Practising physicians do not only consider case reports significant but also use them as a valid reference to understand various medical conditions. See the basics of  how to write a case report below. 

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How, Where, And When To Begin

Following an unusual medical case can be a good start for writing a case report. If you come across something interesting, it is better to discuss it with it your colleagues and other consultants. He/she will guide you or give you more striking information about the particular patient.

Before you begin assessing any patient, seeking permission from the patient’s consultant is a good practice. Once you get the permission and confirmation that no one else is writing a report on the same patient, start your assessment process formally. Discuss and confer the case with colleagues, follow the appropriate investigation and treatment to lay out your preliminary draft.

Follow the in-patient course of treatment during his hospitalization and after his discharge. The patient remains under observation after discharge during his reexamination visits. It will help you track the clinical course and his progress. You should wait for at least six weeks to see the results of the clinical course. In the case of a patient suffering from any rapid or acute illness, you can manage your schedule and timeline while following his neurological examination.

Review Medical Literature

Apparently, this step does not seem important, whereas, it has great functional significance. Discussing the case with colleagues and physicians to assess the clinical scenario does help. However, exploring contemporary research is a quick way to back your case report with literature.

You may take the assistance of your hospital’s nursing station to search for the relevant data. In addition, you can use Google Scholar, Pub Med, Embase, Medline and Ovid to get authentic publications and articles. As a staff member, you can access UpToDate, search for keywords or use individual references.

Furthermore, use the internet as a global forum and join medical communities and discussions. You can post your case with details and de-identified images and petition medical advice from the medical professionals working worldwide. The following forums and communities can be helpful,

  • Neurolist  ( Free-membership)
  • The American Academy of Neurology (AAN) (Free-membership)
  • Sermo® ( Free-membership)

Besides that, teaching grounds of local medical universities, seminars, conferences, simple discussion and presentations are some other beneficial options to seek guidance regarding your case.

Consider the Criteria of Medical Journals

This is an essential step during the preliminary phase of your case report writing. Determining the publishing criteria of medical journals will help you publish your case report. Here is a brief guideline about the publishing criteria of BMRCN and JMCR:

Bio Med Central Research Notes (BMRCN)

  • A case report must describe a clinical case.
  • All the cases must be authentic, presenting educational value to the medical domain.
  • The case report must not present therapeutic interventions and medical preventives, as they require considerable evidence.

 Journal of Medical Case Report (JMCR)

  • A case report must contribute to medical knowledge significantly.
  • Case report must discuss the following things:
    • Unreported side effects of the medication used in the treatment
    • Any new variation involved in the disease process
    • Unexpected disease presentation
    • Unexpected links between symptoms and disease
    • Details of diagnosis, treatment, and management
    • Any unexpected event during treatment as a result of clinical treatment
    • Significant findings to shed light on adverse effects of the disease

How to Format Case Report

The word limit varies from journal to journal, but most reports are not too long. We will advise you to draft a case manuscript with the pertinent details. You can take assistance from the given format generally adopted for writing the case report:

1. Title Page

The first page must be a title page, including a short, comprehensive description of your manuscript, full names of author and participants, institutional and email addresses. You must identify the corresponding author clearly. Avoid using abbreviations, puns, and cute wordings on the title page, as they create obscurity.

2. Abstract

A concise description of the case report, not more than 350 words, is part of the abstract. Structure the abstract into three categories:

  • Background: This vignette in your report elaborates the significance of the case in the medical domain. The background should reflect the exclusivity of your manuscript in terms of its importance to the medical literature.
  • Case Presentation: The case presentation lists the nature of the ailment, the patients’ demographic information, gender, age, and ethnic background.
  • Conclusion: The conclusion is a summary of the findings and learning points for the medical professionals, including clinical impacts of the case report. The conclusion also lists if the report deals with a specific clinical specialty or it will have a clinical impact on a broader spectrum.

Keep the information in the abstract as succinct as you can, as it is one of the important parts of your report. These are the details most researchers will go through first to build up their interest in the report.

3. Keywords

Add a keyword section, comprising of a list of keywords you use in the case report. It will enable researchers to retrieve the content online easily.

4. Introduction or Background

This part explains the disorder, its treatment, and progression. You must include a comprehensive presentation to explain a new disease. If your case report discusses the adverse effects of any drug interaction, incorporate relevant information regarding drug use and its side effects. Providing brief background information to support the case report in the introduction is a good idea. It will help the readers understand the standpoint of contemporary researches in that particular area. The ending statement of an introduction should briefly recapitulate the objective of the case report.

5. Case Presentation (CP)

Along with the patient’s demographic information, the case presentation includes patient’s medical history, signs, and symptoms of the disease, description of medical tests or intervention. As an integral section of the report, the case presentation should be in chronological order, explaining primary complaints, ailment history (including family and social history with details of medications the patient takes for allergies). In addition, CP should include physical examination details, vital symptoms of the disease on the initial stage, and a brief description of the results.

6. Discussion

You can incorporate this section to make the case report more comprehensive by adding additional information. This helps researchers perceive the case in the specific medical context, as it evaluates the patient’s case for uniqueness, validity, and accuracy. You can incorporate more references and literature review for an expanded conclusion.

7. Conclusion

This part clearly states the relevance and significance of your case. It further evaluates the impact of your case report on the medical domain. Make sure you add information regarding how your case report advances medical knowledge pertaining to a disease’s etiology, its treatment, and drug mechanism.

8. Patient’s Prospect

Although it is an optional section, you can add it to give a new dimension to your case report. You can add patient’s reflection about his disease, his experiences while seeking medical advice and treatments, and description of symptoms. However, to avoid making it subjective or patient-centered, you should add only relevant details in the report.

9. Ethical Consideration

It is a compulsory section in both JMCR and BMC guidelines. You need to seek the patient’s consent for publishing his case report in the medical journal. You have to submit a statement in writing to the BMC along with your manuscript.

10. Compulsory Sections of a Formal Report

  • Abbreviation List: Provide a list of abbreviated words used in the content.
  • Authors’ Contribution: This is a section acknowledging the individual contribution of each author.
  • Author Information: Include author’s name, current position, and background information.
  • Acknowledgement:Acknowledge people, who contributed to design, interpret, analyze and conceptualize the report.
  • References and Cover Letter: Include and cite at least 15 references in the manuscript. Add a cover letter (for Editor-in-Chief) stating the purpose, and significance of your report.

Submission Guidelines

Before submission, you need to:

  • Consider the aims of the journal you want to submit
  • Revise fees policies
  • Ensure the accuracy and readability of the case report
  • Follow the copyright agreement policy
  • Follow the formatting guidelines
  • Agree to the journal’s editorial policies

Bottom Line

Overall, reports adhere to a formal case report format but if you have a passion to share your medical experience and insights with people, it can become a lifelong hobby. Thus, the above-mentioned guidelines will definitely help you write a coherent, clear and impactful case report for publication to benefit the scientific community.

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