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Tips for writing a case report for the novice author
A case report is a description of important scientific observations that are missed or undetectable in clinical trials. This includes a rare or unusual clinical condition, a previously unreported or unrecognized disease, unusual side effects to therapy or response to treatment, and unique use of imaging modalities or diagnostic tests to assist diagnosis of a disease. Generally, a case report should be short and focussed, with its main components being the abstract, introduction, case description, and discussion. This article discusses the essential components of a case report, with the aim of providing guidelines and tips to novice authors to improve their writing skills.
For many doctors and other healthcare professionals, writing a case report represents the first effort at getting articles published in medical journals and it is considered a useful exercise in learning how to write scientifically due to similarity of the basic methodology. 1 Case reports aim to convey a clinical message. 2 , 3 Despite different types of case reports, they all aim to enhance the reader's knowledge on the clinical manifestations, the diagnostic approach (with a focus on imaging modalities for case reports published in medical imaging/radiology journals), or the therapeutic alternatives of a disease. 2 – 4 Thus, a case report worthy of reading should contain both useful practical messages and educational purpose. 2 – 5
Although case reports are regarded by some as the lowest (some even do not list the case reports at all) in the hierarchy of evidence in the medical literature, publishing case reports allow for anecdotal sharing of individual experiences, providing essential sources of information for the optimum care of patients. In the hierarchy of evidence-based medicine, randomized controlled trials are placed at the top, superseded by systematic reviews and meta-analyses, followed by prospective experimental trials, then observational studies, case–control studies, and case series at the bottom. 1 , 6 – 8 Most authors are now aware of the impact factor of journals to which they submit their studies. Case reports are infrequently cited, and therefore, publishing case reports is likely to decrease the journal's impact factor. 9 This has led many editors to remove case report sections from their journals. 10
On the other hand, it has been pointed out by others that case reports that are carefully prepared and interpreted with appropriate caution play a valuable role in both the advancement of medical knowledge and the pursuit of education. 11 – 16 Vandenbroucke 17 listed five roles of potential contribution to defend the publication of case reports:
- Recognition and description of a new disease
- Recognition of rare manifestations of a known disease
- Elucidation of the mechanisms of a disease
- Detection of adverse or beneficial side effects of drugs (and other treatments)
- Medical education and audit
Two main roles are recognized for case reports published in medical imaging and radiology journals: as sources of new knowledge and as important means for education and learning. The case report as a source of new knowledge refers to visualization of a new manifestation or finding, or clearer demonstration of a known feature of a disease, using a new imaging technology or an imaging method. 18 , 19 Figure 1 is an example showing 3D virtual endoscopy and the unique intraluminal views of the coronary lumen provided by this new visualization tool. 18 The case report as a means for teaching and learning can be manifested as publication of characteristic and instructive cases for educational features. An example is that British Journal of Radiology (BJR) used to publish six to seven case reports in its monthly issue; however, it has changed the format to publishing “Case of the Month” since May 2012. Educational value instead of extreme rarity is the main virtue of a case report worthy of publication. 2 , 3
Multiplanar reformatted image showing the left coronary artery with coronary stent implanted (arrows) at the ostium of left main stem (A). Virtual endoscopy views of the proximal segment of left coronary artery (B), left anterior descending (C), and left circumflex (D). The internal wall of these coronary branches looks smooth on virtual endoscopy images with no sign of intraluminal irregularity. (Reprint with permission from Reference. 18 )
Writing a case report can be educational for the author as well as for potential readers. 13 Whether in the context of reporting something potentially new or presenting an instructive example of something well known, the author's first and most important task is to search and read extensively on the topic. 20 This article aims to provide guidance on the novice author for writing case reports. Although it is recognized that these guidelines and tips for writing case reports are insufficient for making a successful author, they do help inexperienced authors to exercise and develop basic skills needed in medical writing.
The structure of the case report
Case reports are shorter than most other types of articles. Case reports should encompass the following five sections: an abstract, an introduction with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, and a brief summary of the case and a conclusion. 21 , 22 Tables, figures, graphs, and illustrations comprise the supplementary parts and will enhance the case report's flow and clarity. Unlike original articles, case reports do not follow the usual IMRAD (introduction, methods, results, and discussion) format of manuscript organization. As the format for case reports varies greatly among different journals, it is important for authors to read carefully and follow the target journal's instructions to authors.
The title is the first component of a case report that will be read by readers. Therefore, it should be concise, informative, and relevant to the subject. The ideal title should attract the reader's attention and state the focus on a particular issue, without being too cumbersome or artificial. 23 Redundant words such as “case reports” or “review of the literature” should be omitted, and ostentatious words such as “unique case” or “first report of” should be avoided. 1 , 5 Table 1 lists the titles of case reports that were published in BJR ( British Journal of Radiology ) and JMIRO ( Journal of Medical Imaging and Radiation Oncology ) between 2012 and 2013.
A list of case reports published in BJR and JMIRO between 2012 and 2013
IVC, inferior vena cava; CPD, continuing professional development.
Like other types of articles, it is necessary to include a short summary that gives an overall idea about the content of the case report. The abstract is usually quite brief and generally shorter than that for other types of articles, and it typically has a word limit of 100 words or less. The abstract should be unstructured, pose the clinical question or diagnostic problem, and provide essential information which allows for easier retrieval from electronic database and helps researchers determine their levels of interest in the case report. 5
The introduction should be concise and immediately attract the attention and interest of the reader. The introduction should provide background information on why the case is worth reading and publishing, and provides an explanation of the focus of the case report, for example: “We present/report a case of ….” Merit of the case report needs to be explained in light of the previous literature, thus, a focussed comprehensive literature review is required to corroborate the author's claim in this section. The author should bear in mind that a more detailed literature review belongs to the discussion, although critical evaluation of the literature is still required. 5 For some journals, such as BJR (case of the month), there is no Introduction section and the body of the case reports starts immediately with a description of the case.
The case description/summary
The case description or summary is the focus of the case report. The case is best presented in chronological order and in enough detail for the reader to establish his or her own conclusions about the case's validity. 5 , 21 The current medical condition and medical history, including relevant family history, should be clearly described in chronological order, typically comprising clinical history, physical examination findings, investigative results, including imaging and laboratory results, differential diagnosis, management, follow-up, and final diagnosis. 1 , 24 The following paragraph is an example of describing the patient's history:
A 34-year-old female was admitted to the outpatient department due to an increasing lump on the right thigh, which she stated as having been present for 5 years. A painful feeling sometimes occurred in the right upper leg. There was no complaint of lower limb weakness, no history of trauma and the patient was otherwise in good health. On physical examination, a deep seated round mass was detected and located on the right thigh with a size of 25 × 25 × 15 cm, showing hard consistency and non-mobile features ( Fig. 2 A). 25 Open in a separate window Figure 2 (A) Photograph showing a huge lump in the anterior part of the right thigh. (B) Radiographs revealed a bulged soft tissue mass in anterior compartment of right lower thigh showing predominantly radiolucent density with multiple chondroid matrix of calcification. Bone structure is still intact. (Reprint with permission from Reference. 25 )
All important negative findings should also be provided. The author's own interpretation or inferences should be avoided in the body of a case report. Tables/figures should be used to reveal chronological findings or to compare observations using different methods. The following paragraph is another example on the detailed description of using different methods both imaging and diagnostic:
Radiographs showed a bulge soft tissue mass in the right lower thigh having predominantly radiolucent density with multiple chondroid matrix of calcification ( Fig. 2 B), but the bone cortex is still intact. An MRI was obtained to further define the extent and nature of the lesion, confirming heterogeneous soft tissue mass in the anterior compartment of the muscle of the right lower thigh which mostly consisted of fat tissue, thick septation and some nodular non-adipose components. T2-weighted images through the tumour demonstrated high signal intensity comparable with the signal intensity of fat. Fat-suppressed T2-weighted images through the distal part of the tumour showed suppression of the signal through the central fatty components and lobular high signal intensity component at the peripheral rim. 25
In particular, figures need a brief but clear description. In the case of surgery and pathology specimens, the author is advised to provide a comprehensive summary of the surgical procedure and detailed pathologist's report. 5 , 25 The following paragraph is an excerpt from the case report published in the Australasian Medical Journal (AMJ):
The patient was admitted to the surgical ward with preparation for open surgery. The abdomen was opened through the site of the previous incision, and an abscess was observed and drained. A hole was detected in the peritoneal fascia. The anterior duodenum was oedematous and thickened with coverage of fibrin. A small perforated duodenal ulcer was seen. Graham patch procedure was performed to repair the perforated duodenal ulcer with two drains put in place and then the abdomen was closed. The patient was managed with intravenous fluids, as well as analgesics and antibiotics. 26
It is worth noting that patient confidentiality must be preserved. Patient demographics such as age and gender, and occasionally, race and occupation are referred to in the first sentence. In order to reduce the possibility of identifying the patient, the patient's initials, date of birth, and other identifiers such as hospital number must not be used.
The discussion is the most important section of the case report. The discussion serves to summarize and interpret the key findings of the case report, to contrast the case report with what is already known in the literature and justify its uniqueness, to derive new knowledge and applicability to practice, and to draw clinically useful conclusions. 2 , 21 In comparing the new case with prior knowledge, the author should briefly summarize the published literature and show in what aspect the present case differs from those previously published, and thus deserves to be read and published. The discussion section of a case report is not designed to provide a comprehensive literature review and citation of all references; therefore, all the references cited should be critically evaluated.
Any limitations of the case should be stated and the significance of each limitation described. The value that the case adds to the current literature should be highlighted, so should the lessons that may be learnt from the case presented, especially if new recommendations for patient diagnosis (with use of an imaging modality) or management, could be put forward. 2 , 5 , 21 The following paragraph is an excerpt from a case report with regard to the concluding statement in the discussion:
This case report highlights the importance of using CT in making accurate diagnosis in patients with abdominal pain due to suspected GI tract perforation. In particular, appropriate selection of CT scanning protocol, such as with oral contrast administration is necessary to ensure timely diagnosis and improve patient management. 26
In the last paragraph, the author should provide the main conclusion of the case report based on the evidence reviewed in the discussion section. A concise statement of the lesson to be learnt from the case could be stated with justifiable evidence-based recommendations. This section should be concise and not exceed one paragraph. 14 , 21
The references listed at the end of the case report should be carefully chosen by virtue of their relevance. References should provide additional information for readers interested in more detail than can be found in the case report, and they should support any specific points highlighted. 14 Some journals restrict the number of references to no more than 15 for a case report.
A case report will not have as much potential impact on the clinical practice of healthcare as randomized controlled trials or other research articles. However, case reports provide valuable sources of new and unusual information for clinicians to share their anecdotal experiences with individual cases, make others aware of unusual presentations or complications, and deliver the educational and teaching message. Well-written and appropriately structured case reports with meticulous attention to the very minute details will contribute to the medical literature and can still enrich our knowledge in today's evidence-based medical world. Table 2 provides the suggested checklist for reporting case reports. Guidelines and tips for writing case reports are not enough for becoming a successful author; however, they are considered helpful for inexperienced or novice authors to exercise and improve their skills needed in medical writing.
Checklist for writing case reports (based on advice in existing literature). 27
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Writing a case report in 10 steps
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- Victoria Stokes , foundation year 2 doctor, trauma and orthopaedics, Basildon Hospital ,
- Caroline Fertleman , paediatrics consultant, The Whittington Hospital NHS Trust
Victoria Stokes and Caroline Fertleman explain how to turn an interesting case or unusual presentation into an educational report
It is common practice in medicine that when we come across an interesting case with an unusual presentation or a surprise twist, we must tell the rest of the medical world. This is how we continue our lifelong learning and aid faster diagnosis and treatment for patients.
It usually falls to the junior to write up the case, so here are a few simple tips to get you started.
Begin by sitting down with your medical team to discuss the interesting aspects of the case and the learning points to highlight. Ideally, a registrar or middle grade will mentor you and give you guidance. Another junior doctor or medical student may also be keen to be involved. Allocate jobs to split the workload, set a deadline and work timeframe, and discuss the order in which the authors will be listed. All listed authors should contribute substantially, with the person doing most of the work put first and the guarantor (usually the most senior team member) at the end.
Gain permission and written consent to write up the case from the patient or parents, if your patient is a child, and keep a copy because you will need it later for submission to journals.
Gather all the information from the medical notes and the hospital’s electronic systems, including copies of blood results and imaging, as medical notes often disappear when the patient is discharged and are notoriously difficult to find again. Remember to anonymise the data according to your local hospital policy.
Write up the case emphasising the interesting points of the presentation, investigations leading to diagnosis, and management of the disease/pathology. Get input on the case from all members of the team, highlighting their involvement. Also include the prognosis of the patient, if known, as the reader will want to know the outcome.
Coming up with a title
Discuss a title with your supervisor and other members of the team, as this provides the focus for your article. The title should be concise and interesting but should also enable people to find it in medical literature search engines. Also think about how you will present your case study—for example, a poster presentation or scientific paper—and consider potential journals or conferences, as you may need to write in a particular style or format.
Research the disease/pathology that is the focus of your article and write a background paragraph or two, highlighting the relevance of your case report in relation to this. If you are struggling, seek the opinion of a specialist who may know of relevant articles or texts. Another good resource is your hospital library, where staff are often more than happy to help with literature searches.
How your case is different
Move on to explore how the case presented differently to the admitting team. Alternatively, if your report is focused on management, explore the difficulties the team came across and alternative options for treatment.
Finish by explaining why your case report adds to the medical literature and highlight any learning points.
Writing an abstract
The abstract should be no longer than 100-200 words and should highlight all your key points concisely. This can be harder than writing the full article and needs special care as it will be used to judge whether your case is accepted for presentation or publication.
Discuss with your supervisor or team about options for presenting or publishing your case report. At the very least, you should present your article locally within a departmental or team meeting or at a hospital grand round. Well done!
Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare that we have no competing interests.
Writing a Case Report
This page is intended for medical students, residents or others who do not have much experience with case reports, but are planning on writing one.
What is a case report? A medical case report, also known as a case study, is a detailed description of a clinical encounter with a patient. The most important aspect of a case report, i.e. the reason you would go to the trouble of writing one, is that the case is sufficiently unique, rare or interesting such that other medical professionals will learn something from it.
Case reports are commonly of the following categories :
- Rare diseases
- Unusual presentation of disease
- Unexpected events
- Unusual combination of diseases or conditions
- Difficult or inconclusive diagnosis
- Treatment or management challenges
- Personal impact
- Observations that shed new light on a disease or condition
- Anatomical variations
It is important that you recognize what is unique or interesting about your case, and this must be described clearly in the case report.
Case reports generally take the format of :
2. Case presentation
3. Observations and investigation
Does a case report require IRB approval?
Case reports typically discuss a single patient. If this is true for your case report, then it most likely does not require IRB approval because it not considered research. If you have more than one patient, your study could qualify as a Case Series, which would require IRB review. If you have questions, you chould check your local IRB's guidelines on reviewing case reports.
Are there other rules for writing a case report?
First, you will be collecting protected health information, thus HIPAA applies to case reports. Spectrum Health has created a very helpful guidance document for case reports, which you can see here: Case Report Guidance - Spectrum Health
While this guidance document was created by Spectrum Health, the rules and regulations outlined could apply to any case report. This includes answering questions like: Do I need written HIPAA authorization to publish a case report? When do I need IRB review of a case report? What qualifies as a patient identifier?
How do I get started?
1. We STRONGLY encourage you to consult the CARE Guidelines, which provide guidance on writing case reports - https://www.care-statement.org/
Specifically, the checklist - https://www.care-statement.org/checklist - which explains exactly the information you should collect and include in your case report.
2. Identify a case. If you are a medical student, you may not yet have the clinical expertise to determine if a specific case is worth writing up. If so, you must seek the help of a clinician. It is common for students to ask attendings or residents if they have any interesting cases that can be used for a case report.
3. Select a journal or two to which you think you will submit the case report. Journals often have specific requirements for publishing case reports, which could include a requirement for informed consent, a letter or statement from the IRB and other things. Journals may also charge publication fees (see Is it free to publish? below)
4. Obtain informed consent from the patient (see " Do I have to obtain informed consent from the patient? " below). Journals may have their own informed consent form that they would like you to use, so please look for this when selecting a journal.
Once you've identified the case, selected an appropriate journal(s), and considered informed consent, you can collect the required information to write the case report.
How do I write a case report?
Once you identify a case and have learned what information to include in the case report, try to find a previously published case report. Finding published case reports in a similar field will provide examples to guide you through the process of writing a case report.
One journal you can consult is BMJ Case Reports . MSU has an institutional fellowship with BMJ Case Reports which allows MSU faculty, staff and students to publish in this journal for free. See this page for a link to the journal and more information on publishing- https://lib.msu.edu/medicalwriting_publishing/
There are numerous other journals where you can find published case reports to help guide you in your writing.
Do I have to obtain informed consent from the patient?
The CARE guidelines recommend obtaining informed consent from patients for all case reports. Our recommendation is to obtain informed consent from the patient. Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports before publishing. The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible). Please consider this as well.
If required, it is recommended you obtain informed consent before the case report is written.
An example of a case report consent form can be found on the BMJ Case Reports website, which you can access via the MSU library page - https://casereports.bmj.com/ . Go to "Instructions for Authors" and then "Patient Consent" to find the consent form they use. You can create a similar form to obtain consent from your patient. If you have identified a journal already, please consult their requirements and determine if they have a specific consent form they would like you to use.
Once you have written a draft of the case report, you should seek feedback on your writing, from experts in the field if possible, or from those who have written case reports before.
Selecting a journal
Aside from BMJ Case Reports mentioned above, there are many, many journals out there who publish medical case reports. Ask your mentor if they have a journal they would like to use. If you need to select on your own, here are some strategies:
1. Do a PubMed search. https://pubmed.ncbi.nlm.nih.gov/
a. Do a search for a topic, disease or other feature of your case report
b. When the results appear, on the left side of the page is a limiter for "article type". Case reports are an article type to which you can limit your search results. If you don't see that option on the left, click "additional filters".
c. Review the case reports that come up and see what journals they are published in.
2. Use JANE - https://jane.biosemantics.org/
3. Check with specialty societies. Many specialty societies are affiliated with one or more journal, which can be reviewed for ones that match your needs
4. Search through individual publisher journal lists. Elsevier publishes many different medical research journals, and they have a journal finder, much like JANE ( https://journalfinder.elsevier.com/ ). This is exclusive to Elsevier journals. There are many other publishers of medical journals for review, including Springer, Dove Press, BMJ, BMC, Wiley, Sage, Nature and many others.
Is it free to publish ?
Be aware that it may not be free to publish your case report. Many journals charge publication fees. Of note, many open access journals charge author fees of thousands of dollars. Other journals have smaller page charges (i.e. $60 per page), and still others will publish for free, with an "open access option". It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish. MSU-CHM does NOT have funds to support publication costs, so this is an important step if you do not want to pay out of pocket for publishing
*A more thorough discussion on finding a journal, publication costs, predatory journals and other publication-related issues can be found here: https://research.chm.msu.edu/students-residents/finding-a-journal
Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. 2013. The CARE guidelines: Consensus-based clinical case reporting guideline development. Glob Adv Health Med . 2:38-43. doi: 10.7453/gahmj.2013.008
Riley DS, Barber MS, Kienle GS, AronsonJK, von Schoen-Angerer T, Tugwell P, Kiene H, Helfand M, Altman DG, Sox H, Werthmann PG, Moher D, Rison RA, Shamseer L, Koch CA, Sun GH, Hanaway P, Sudak NL, Kaszkin-Bettag M, Carpenter JE, Gagnier JJ. 2017. CARE guidelines for case reports: explanation and elaboration document . J Clin Epidemiol . 89:218-234. doi: 10.1016/j.jclinepi.2017.04.026
Guidelines to writing a clinical case report. 2017. Heart Views . 18:104-105. doi: 10.4103/1995-705X.217857
Ortega-Loubon C, Culquichicon C, Correa R. The importance of writing and publishing case reports during medical education. 2017. Cureus. 9:e1964. doi: 10.7759/cureus.1964
Writing and publishing a useful and interesting case report. 2019. BMJ Case Reports. https://casereports.bmj.com/pages/wp-content/uploads/sites/69/2019/04/How-to-write-a-Case-Report-DIGITAL.pdf
Camm CF. Writing an excellent case report: EHJ Case Reports , Case of the Year 2019. 2020. European Heart Jounrnal. 41:1230-1231. https://doi.org/10.1093/eurheartj/ehaa176
*content developed by Mark Trottier, PhD
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Division of Cardiology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
Copyright © 2022 Kosin University College of Medicine.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/ ) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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General principles of case reports, format for writing a case report, conclusions, article information.
- Medical research has become an important part of providing care to patients. Case reports published in medical journals can communicate information to the medical community about rare or unreported features, conditions, complications, or interventions. Case reports are generally short, focusing on key components such as a summary and introduction, case presentation, and discussion. Authors now have access to free, continuously updated case reports of different types from multiple journals. This review introduces the process and mechanisms for how and when to prepare a case report. We briefly review the editorial process of each of these complementary journals, along with author anecdotes, hoping to inspire authors to write and continue writing case reports; and discusses the essentials of a case report, aiming to provide guidelines for improving medical writing skills.
- Keywords : Case reports ; Guideline ; Medical writing ; Publications
Conflicts of interest
Sung Il Im is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflicts of interest relevant to this article were reported.
We would like to express our gratitude to the editorial board members of Kosin Medical Journal .
All the work was done by SII.
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- How to write an original article in medicine and medical science
How to write a case report: an easy, step-by-step guide to writing a clinical case report.
I hope you enjoy reading this blog post.
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Hello everyone! Welcome to our tutorial and a step-by-step guide on how to write a Case Report.
- 1 Patient: Case Report
- 2-4 Patients: Case Report or Case Series
- >4 Patients: Case Series
- Google your disease/case + case report. Go through the first page of results, how many of these links are actual publications? How many of these are links to PubMed ?
- Go to PubMed and repeat the search. You can gauge the number of hits you get, use the filter -> case report or command/control + f “case report” to count how many of the results are case reports. Pay special attention to the year and journal in which they were published. Be careful that the PubMed filter is not always accurate. For a full guide on how to perform a literature review, check out our Comprehensive Research Course, from Idea to Publication.
- Go through the case reports you found and read them. How different or similar are they to your own case?
- Did my search for clinical case report yield case reports or large cohort/comparative studies? How many similar studies did I find? If you found only case reports and case series then your case may be “rare” enough to be publishable. On the other hand, if your search yielded cohort/comparative/case-control studies then it’s likely that there’s ample evidence and more complex studies available, reducing the attractiveness of your case report UNLESS there’s something truly unique about your case.
- If your search yielded case reports or series, which were more common? If you have only one patient and there are various case series with >10-20 patients, then your publication may not be as publishable UNLESS there’s something significantly different about your case. The same applies if you find 5-10 case reports about the same topic. Your case report has to bring something unique, something different that we don’t already know from existing literature.
- How different is your case from everything you read?
In theory, every specialty publishes case reports. However different specialties will have different interests in what a case report should include. For example, a case report for a radiology journal will have a different focus than if it was written for a surgical journal. For the former, readership and editors might find details related to radiologic findings to be more interesting than surgical pictures and vice versa.
Additionally, some specialties have dedicated journals to case reports. For example, urology has Journal of Endourology – Case Reports. For Surgery, there are journals such as the Journal of Surgical Case Reports that solely publish case reports.
Like most published literature, case reports follow a structure which typically consists of:
- Case Presentation
The CARE guidelines are generally regarded as the standard “checklist” for publishing a quality case report and some journals ask for the checklist to be submitted along with the manuscript. Here you can find more information about the CARE guidelines: https://www.care-statement.org/
Once you’ve gauged the literature for the feasibility of publishing, you should gather all the possible case information. You can use the case reports you found as a guide as to what you’ll need, but in general, try to obtain data on:
- Accurate presentation, physical exam findings and relevant patient history.
- Lab values and imaging studies, when necessary, some diseases also benefit greatly from pathology slides.
- Treatment: specifics on duration of pharmacologic therapy, if it was surgical, nuanced description and pictures of the surgery.
- Follow-up results: For certain conditions, a longer follow-up is needed. You can gauge this from other published case reports.
- Patient satisfaction or measured outcomes. There is a plethora of scales that attempt to objectively measure subjective components such as functionality, pain and quality of life. Additionally, all specialties have their own internal scores used to assess severity and treatment usefulness such as the SPSS for benign prostatic hyperplasia, the EuroQoL quality of life score and so on.
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Case report’s introductions are very similar in structure and purpose to any other published study. The aim of any introduction is to give background about the topic you are presenting. Typically, introductions have 3-4 paragraphs. For case reports, introductions might be 1-2 paragraphs or sometimes even a few lines based on the word limit allowed by the journal. Think of a funnel or an inverted triangle where you go from general/broad to specific. Your prior literature review should help you fill out the paragraphs.
The first paragraph will typically: describe the disease, etiology, and provide brief epidemiologic data in 2-3 sentences. This is usually followed by typical clinical presentations or other related findings/or treatments. In a broad sense, the first paragraph is a very general summary of the background of this condition.
The second paragraph will transition into setting the context as to why your case is important or different. Why there’s a gap or need for this case. Think of it as selling or pitching something. Depending on your case and its focus it will range from a rare presentation or findings to variations in treatments or procedures.
Lastly, your last paragraph is a brief, concise summary of what the report entails, usually something like “We present a case report of X condition treated successfully with X technique and adequate outcomes”.
When writing your first introduction it’s easy to get overly excited and extend too much. It’s important to stay focused and on-topic. A good rule of thumb is to keep introductions at around 300 words.
Another important point to keep in mind is the context of your readership and make it understandable for a broad readership.
Let’s start with a short introduction that condenses all the above-mentioned points in a single paragraph. The following case report “Dangerous mistake: an accidental caffeine overdose” published in BMJ Case Reports will be our first example.
1 st Paragraph “This case illustrates the life-threatening consequences, such as malignant cardiac arrhythmias, of severe caffeine poisoning, which is a rare event. Also, it highlights the risk of accidental caffeine overdose associated with sports practice, which can be related, not only, to the difficulty in measuring small portions, but also due to unclear consumer’s instructions.”
As we go through examples, you’ll see the various ways introductions or backgrounds can be written to serve specific purposes. In this case, the brief background/introduction is centered on “justifying” the importance of the case.
Abstracted from: Andrade A, Sousa C, Pedro M, Fernandes M. Dangerous mistake: an accidental caffeine overdose. BMJ Case Rep. 2018;2018:bcr2018224185. Published 2018 Jun 8. doi:10.1136/bcr-2018-224185
1 st paragraph
“A gallstone ileus is a mechanical intestinal obstruction caused by a gallstone impaction within the gastrointestinal tract. It mainly occurs following the formation of a cholecystoenteric fistula, most commonly in the duodenum and secondly in the colon. A cholecystocolonic fistula (CCF) is a late complication of repeated episodes of chronic inflammation of the…Impaction of a gallstone in the sigmoid colon causing a large bowel obstruction is rare and it’s usually at the sites of previous inflammation or colonic disease”
In this excerpt abstracted from the article, notice how it plays the role of the 1 st and second paragraph by introducing gallstone ileus and mentioning how fistulation between the gallbladder and colon are rarer (and later ties down this fact by mentioning that there are only 250 reported cases).
2 nd Paragraph
“Here we present a case of a 49-year-old female patient presenting with abdominal pain and bowel obstruction due to a gallstone impaction on the sigmoid colon due to a CCF. No more than 250 cases have been reported; a review of the literature of this rare condition is also revised. The work has been reported in line with the SCARE criteria”
Since the previous paragraph covered the essential functions of the typical paragraphs 1 and 2, in this example, paragraph 2 presents a summary of what will be presented (which is typically paragraph 3)
Alternatively, introductions can be lengthened a bit if needed, as in this example from “Balo’s Concentric Sclerosis with monophasic course: A report of 2 cases” published in Annals of Medicine and Surgery
1 st Paragraph
“Balo’s Concentric Sclerosis (BCS) is a rare demyelinating disease considered a variant of multiple sclerosis (MS). It presents acutely with focal neurological deterioration. Magnetic Resonance Imaging (MRI) is the diagnostic modality, which usually reveals concentric lamella in cerebral white matter with “onion-like” lesions…”
“BCS often affects young adults and three different clinical courses have been described; including an acute and self-limiting, remittingrelapsing variant and rapidly progressive primary disease. These last 2’s clinical and radiological characteristics appear to be more strongly related to MS. BCS usually courses with solitary lesions, which may persist for years. These lesions may regress and resemble typical demyelinating plaques.”
3 rd Paragraph
“BCS is a variant of MS or separate entity. Prior authors have hypothesized increased risk of progression to MS when multiple bands and/or oligoclonal bands are found. In this report we describe two patients presenting at an academic institution with BCS, which presented with a monophasic course, and characteristic Balo lesions in MRI that disappeared during a long term follow up.”
Abstracted from: Martinez HR, Rodriguez-Gonzalez IC, Escamilla-Garza JM, Figueroa-Sanchez JA, Garcia-Aleman AC, Hinojosa-Gonzalez DE. Balo’s Concentric Sclerosis with monophasic course: A report of 2 cases. Ann Med Surg (Lond) . 2021;68:102602. Published 2021 Jul 28.
First human face allograft: early report https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68935-6/fulltext Metastatic Cutaneous Apocrine Adenocarcinoma Treated With a Combination of Pertuzumab-Based Targeted Therapy and Taxane Chemotherapy A Case Report https://jamanetwork.com/journals/jamadermatology/fullarticle/2436320 Deformation of cranioplasty titanium mesh in a paediatric patient following head trauma https://pubmed.ncbi.nlm.nih.gov/31189547
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- Treatment: specifics on duration of pharmacologic therapy, if it was surgical, surgical technique along with intraoperative photos.
- Follow-up results: For certain conditions, a longer follow-up is needed, you can gauge this from other published case reports.
- Patient satisfaction or outcomes. For most pathologies, there are verified classification scores and other scales that are applicable to objectively measure outcomes that may be subjective to a degree. As examples, Euro QoL measures quality of life in general, USSQ for ureteral stent wearers, mini-mental for cognitive assessment and so on. Additionally, patient input per se may be used in the case report if they have an objective assessment of their own outcomes or satisfaction.
“A 32-year-old woman with no significant medical and family history presented to the local emergency department (ED) referring malaise, anxiety, dizziness and nausea. Symptoms like chest pain, syncope, palpitations or fever were denied. The initial physical examination at triage revealed a Glasgow Coma Scale (GCS) of 15, a respiratory rate of 19 breaths/min, 100% oxygen saturation on room air, blood pressure of 112/70mm Hg, pulse of 80 beats/min and had a normal tympanic temperature. Also, the blood sugar was 147mg/dL. After observation, the patient had an episode of presyncope followed by agitation and vomiting. At this point, the patient was pale and sweaty with a GCS of 11 (eye opening: 4; verbal response: 2; motor response: 5), blood pressure of 115/75mm Hg, tachycardia (160 beats/min) and 99% oxygen saturation on room air…”
It is always best to start with presentation and past relevant history. However, it’s important to keep the context of the patient and the journal being submitted to in mind. For example, in this case in the emergency department, blood pressure, heart rate, saturation, GCS are all very important, whereas in a pathology focused case report they might not.
“The initial group of complementary exams was: ► Electrocardiogram (figures 2 and 3) showing a broad QRS polymorphic tachycardia. ► Arterial blood gas showed a metabolic acidosis with pH of 7.296 (7.35–7.45), pCO2 of 29.9mm Hg, pO2 of 117mm Hg, HCO3 of 16.1mmol/L (22–26) and severe lactataemia with serum lactate level of 5.3mmol/L (0.5–1.6). ► Prominent laboratory findings included mild leucocytosis of 13.50×109 /l (4.0–10.0) with 68.3% neutrophils, hyperglycaemia of 254mg/dL (70–105), hypocalcaemia of 2.5mmol/L (3.5–5.1) and hypophosphataemia of 1.8mg/dL (2.3–4.7). Magnesium and calcium serum values were within normal range as well as thyroid, renal and liver function tests. Urinalysis was positive for ketones and glucose and negative for cocaine and opioid drugs.”
Work up should follow on the premises set during the initial presentation and case history. While some patients may have undergone a plethora of tests, try to focus on the ones relevant to the presentation. For example, in this case, treating physicians were working up a possible intoxication as a main diagnosis, in such case if the patient underwent additional unrelated testing (as a ridiculous example, a colonoscopy) it may be better to omit to keep the sections short and concise.
“The supportive treatment, including intravenous fluids, propranolol, potassium and phosphorus supplementations, stabilised the patient’s clinical status. No activated charcoal was administered as the medical team was unaware of a dietary product ingestion during the initial evaluation. After 48hours of observation in our intermediate care unit, the patient was transferred to the ward, since she only had a asymptomatic sinus tachycardia (maximum of 120 beats/min), with other vital signs remaining stable and normal serum pH, lactate and glucose levels.”
“The patient remained in our intermediate care unit for 2 days, with normal level of
Outcomes and follow-up are one of the most important sections of the case report, make
consciousness maintained, normalisation of arterial blood gas values and no recurrence of presyncope episodes. However, she had persistent sinus tachycardia and, for this reason, was submitted to a 3-day course of 30 mg/day oral propranolol with heart rate control. The patient remained clinically stable and 5 days later was discharged asymptomatic referred to internal medicine follow-up… Six months after the episode, at follow-up evaluation, the patient remained asymptomatic.”
sure you include relevant systems/scores and any lingering symptom.
Abstracted from: Andrade A, Sousa C, Pedro M, Fernandes M. Dangerous mistake: an accidental caffeine overdose. BMJ Case Rep . 2018;2018:bcr2018224185. Published 2018 Jun 8. doi:10.1136/bcr-2018-224185
“ A 49-year-old female patient was admitted to the hospital with severe abdominal pain, nausea, vomiting, and constipation following a 3- day history of colicky middle abdominal pain. The patient had no relevant medical history. On examination the patient was hemodynamically stable and afebrile. Physical examination revealed abdominal distension with decreased bowel movements to auscultation accompanied by diffuse tenderness to superficial and deep palpation and a tympanic colonic margin to percussion…”
Presentation and relevant history. Notice how it’s focused on relevant aspects to the scenario in which the patient presented (i.e abdominal pain in the E.R. where hemodynamical stability is important vs a case of a rare condition in an outpatient clinic where it might not be as important)
“Laboratories showed a normal hemoglobin, WBC of 6.7 × 10ˆ 10 and no alterations in liver enzymes, except for an elevation in GGT, with a value of 226UL. Simple abdominal radiographs were performed, observing dilated loops of the small bowel, and no signs of gas in the rectum. A CT was ordered, revealing a 3 × 2 cm calcified mass in the sigmoid colon, suggestive of a gallstone, with associated enlargement of the surrounding intestinal wall, with stranding pericolonic fat and signs of diverticular disease…”
Laboratory, imaging and other work-up. Same concept as above, focused on relevant findings for this patient’s scenario.
“The patient underwent an exploratory laparotomy, and after the abdominal cavity was exposed, signs of dilation of the small intestinal loops became evident. An intraluminal, solid, non-mobile mass was found in the sigmoid colon. An enterolithotomy was performed, and a 4 × 4 cm gallstone was extracted without complications, performing a primary transverse closure of the colon. A fistulous track was observed between the gallbladder and the hepatic flexure of the colon…The patient had an adequate postoperative outcome, referring only moderate pain during the first day. Oral intake was reintroduced on the fourth day, without further complications. On the fifth POD the patient was discharged home, with good oral intake and with norma levacuations. “
Treatment and postoperative course. Since this is a surgical-focused case report, operative technique and a thorough description of the procedure are highly encouraged.
“On a 8 month-follow up, the patient is doing well with no biliary symptoms.”
Example image from the case
Abstracted from: Mauricio GU, David Eugenio HG, Enrique QF. Gallstone ileus of the sigmoid colon caused by cholecystocolonic fistula: A case report. Ann Med Surg (Lond). 2018;31:25-28. Published 2018 Jun 6. doi:10.1016/j.amsu.2018.06.001
Case 1: “ An enhanced MRI showed a periventricular concentric demyelinating lesion in left periventricular area (Fig. 1A and B). Clinical and imagining findings raised suspicion for isolated MS clinical syndrome. A lumbar puncture revealed one OCB, 3 mononuclear cells and normal proteins in CSF. Somatosensorial evoked potentials were compatible with demyelinating disease . “
Case 2: “Stroke protocol MRI revelaed a right sided periventricular concentric demyelinating lesion with a concentric ring pattern that showed enhancement after endovenous contrast injection…The CSF showed normal proteins, no leukocytes and the OCB were negative. “
Case 1: “ The patient received IV methylprednisolone (1000 mg/day for 5 days) showing clinical improvement and was discharged 5 days later without any neurological deficit. His neurologist prescribed interferon, once a week subcutaneously that was suspended one month later due to side effects. Case reassessment from a neurologist consulted for a second opinion suggested BCS. “
Case 2 : “The diagnosis of BCS was established and the patient received IV methylprednisolone. (1000 mg/day for 5 days) and a remarkable clinical improvement was observed and one week later the patient was discharged.
Case 1: “ The patient has remained asymptomatic and 10 years later (September 2020). Follow-up MRI revealed small gliosis in the left periventricular area .”
“She remains asymptomatic eight months after diagnosis.
First human face allograft: early report https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68935-6/fulltext Metastatic Cutaneous Apocrine Adenocarcinoma Treated With a Combination of Pertuzumab-Based Targeted Therapy and Taxane Chemotherapy A Case Report https://jamanetwork.com/journals/jamadermatology/fullarticle/2436320 Deformation of cranioplasty titanium mesh in a paediatric patient following head trauma https://pubmed.ncbi.nlm.nih.gov/3118954
- Similarities and differences to prior published cases in both treatment and outcomes.
- Ponder/extrapolate on why or how those differences might impact selected treatment or outcomes. Open to further discussion such as using techniques in low-resource settings or similar.
- Emphasis on how your case is different and how your treatment or presentation “adds” to the literature.
- Wrap to a “key takeaway” which can be related to presentation, diagnosis, management or follow-up.
Some authors choose to summarize a study or 2 per paragraph and directly compare those findings to their own study while others prefer to provide a general overview without fixating on any one study specifically.
In this example, authors contrast their case and treatment to that of published literature, sometimes addressing changes in standardized or expected treatment.
“ The exact etiology of CCF secondary to gallstone disease may vary. Glenn et al. in their study of a few more than a hundred bilioenteric fistulas, stated that acute inflammation of the gallbladder with obstruction of the cystic duct allows adhesion of the gallbladder to the contiguous organs. This promotes ulceration and ischaemia of the wall of the gallbladder and the adjacent organs, creating an anomalous communication between them…”
Reintroduction of the general context of the case is a great way to set up the discussion which should center on discussing similarities and differences.
“Clinical signs of CCF are usually minimal, and preoperative diagnosis of CCF is rare and only considered in 7.9% of all CCF, therefore the diagnosis is often made intraoperatively. Signs and symptoms of a CCF may vary, as it often presents with abdominal pain, nausea, vomit, diarrhea, weight loss, and malabsorption…”
Clinical presentation as reported in the literature is provided to better assess and contrast how this case was different or similar from the reported literature.
“ Gallstone impaction occurs most frequently in the small intestine, followed by the colon in 8% of the cases. In the vast majority of patients presenting with CCF and biliary ileus, the stone is located at the sigmoid colon. The size of the gallstone is presumed to determine whether and where a migrated stone will impact. Small and mid-sized stones are thought to pass through the entire colon, thus being easily expelled through stools; whereas gallstones over 2.5 cm in diameter may cause colonic obstruction at the sigmoid colon…”
Common impaction locations, again, providing in-depth context. As previously mentioned, it’s important to scrutinize the presented case against published literature as much as possible.
“ Our patient had diverticular disease and a gallstone of 4 cm, predisposing it to impact at this point. Misdiagnosis is common and it also carries a significant rate of complications with a mortality rate ranging from 12% to 27% in most series reported. Preoperatively diagnosis is therefore critical to improve morbidity, mortality and post-operative complications…”
“Treatment of CCF has changed through the years; traditional treatment during the early 80s suggested a ‘‘two-stage’’ procedure, performing a diverting colostomy. Nowadays, a ‘‘one-step’’ management has been considered the treatment of choice without significant complications being reported, versus doing only the enterolithotomy alone…”
Context for treatment and setting up discussion to analyze how frequent is the treatment provided by the authors.
“We opted to perform solely the enterolithotomy because the patient never experienced biliary colic or any other symptoms associated with gallbladder disease. We decided to correct only the occlusion during the laparotomy, as the surgical approach was less complicated, and it had a lower mortality rate. Simple enterolithotomy enthusiasts state the infrequency of recurrent gallstone ileus, and the rarity of complications directly related to a persistent gallbladder fistula, such as cholecystitis, cholangitis, malabsorption and carcinoma of the gallbladder. Also, when the occlusion is resolved, the possibility of spontaneous closure of the fistulous track is higher, leaving behind only a fibrous remnant.”
Rationale for treatment provided by the authors and outcomes.
“Caffeine (1,3,7-trimethylxanthine) is a natural product commonly found in foodstuffs, beverages and medicinal products. When relatively low doses of caffeine are consumed, severe side effects are uncommon. However, in recent years, larger amounts of caffeine have been added to energy drinks or taken as dietary supplements, such as anhydrous caffeine, for increasing endurance, concentration and athletic performance.”
This “review” style discussion begins with a reintroduction of the topic. Authors do this through a similar structure to the one we talked about for introductions. The inverted triangle starting from broad to specific.
“Normally, mild stimulation is obtained with a caffeine dosage of 0.05–0.2g. Even though fatal caffeine intoxication is rare, acute ingestion of >5g can be lethal… By blocking the adenosine receptors, at high doses, caffeine interacts with the sympathetic nervous system inducing prolonged and intensified beta-receptor activation with positive inotropic and chronotropic effects which can trigger arrhytmia. And in toxic doses, caffeine directly releases calcium from intracellular stores, which also may increase the susceptibility for arrhythmias. Symptoms of caffeine intoxication may include headache, fever, nausea, vomiting, tachycardia, dizziness, tinnitus, anxiety, irritability, insomnia and seizures…. Toxic levels of caffeine are also associated with severe hypokalaemia, hyperglycaemia, rhabdomyolysis, renal failure and hyperlactacidaemia…”
Authors then move to talk about specifically caffeine intoxication, its levels and severity as well as mechanism of symptomatology.
“ Treatment of caffeine toxicity can vary on case-to-case basis. However, it should begin with careful and immediate assessment of the patient’s airway, breathing and circulation. Not only should non-invasive monitoring, like continuous cardiac monitoring, and fingerstick glucose level be rapidly obtained, but also intravenous access must be established. To prevent systemic effects of the caffeine metabolism, activated charcoal and intravenous lipid emulsion can be useful interventions. To address hypotension, intravenous fluid therapy with isotonic fluid should be initiated.Any patient with a haemodynamically unstable dysrhythmia should be treated by advanced cardiac life support protocols. In several published case reports, a combination of a shortacting beta-blocker (eg, esmolol, propranolol), procainamide or lidocaine with electrolyte correction successfully treated cardiac arrhytmias…”
Lastly, the authors address treatment and outcomes in their latter paragraphs. Given the rarity of caffeine intoxication, the discussion serves as an overall “primer” for the topic rather than a “classic” discussion where findings of the case are compared and contrasted to the literature.
There’s no fixed cost to publishing. Most journals don’t have any submission or publishing fees. However, some open-access journals, such as those dedicated to publishing case reports typically have fees ranging from 500 to 5000 dollars. Some countries have waivers or discounts for this fee. Ideally, you should look for a journal with no fees. However, keep in mind that most journals with no fees don’t accept case reports while those that accept case reports charge high article processing fees (APCs).
The writing part shouldn’t take more than a few days. However, it might take months from the time you submit the article until it gets accepted and additional months from the time it is accepted until it gets published.
No! Systematic reviews are usually beyond the scope of case reports. However, some case reports may benefit from “brief reviews” in which a non-systematic or standardized search is performed trying to identify all similar cases. If you’re following this guide, probably you performed the literature search prior to starting your case write up and you can include your findings as a summary table.
Like with every other type of publication, the peer-review process and looking around for different journals may take anywhere between months to years. Some journals advertise their time to first decision if you’re in a rush.
Strictly speaking, no. Some journals have limitations on how many authors can be listed on a case report. However, it’s always a good idea to involve a knowledgeable attending as a senior author to provide expertise on the topic as well as it being a great opportunity to consolidate relationships and network.
Consent is required by CARE guidelines and is something you should seek. Some journals have specific consent forms that they require to be submitted with the case. However, the ultimate decision of whether you need a consent will depend on your institution (sometimes case reports with no identifiers and face pictures might not require a consent).
While the answer may vary between institutions, generally you don’t need an IRB for a case report.
That’s it! Hopefully with this info you’ll be well on your way to writing your first case report. Case reports are a great start to any publishing career and are also a great way to learn about scientific writing and interesting diseases. My own journey to publications started with a couple of case reports and now I have over 40 publications of all types! By David Hinojosa, MD David E. Hinojosa-Gonzalez obtained his M.D. from Tecnológico de Monterrey, Mexico in 2020 and led the Surgical Research Outcomes Group for 2 years before joining Massachusetts General Hospital/Harvard Medical School as a Research Fellow in 2021. During this time, he has accumulated over 90 presentations, abstracts, and publications.
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