Writing a case report may appear to be a daunting task at first. However, once you understand the basic structure and format of a case report, things tend to become much easier. For most healthcare professionals, the first article that gets published in a medical journal is usually a clinical case report. A medical case report is meant to describe an unusual or novel occurrence, and consists of a comprehensive description of the clinical features, diagnosis, treatment, and follow-up of a patient.
In this post, we will try to understand the basic structure of a clinical case report. Before you start writing a case report, it is always good to review some case reports that are already published in your target journal. This gives you an idea about the required sequence and format.
Key Components Needed for Writing a Case Report
In general, a clinical case report consists of the following main components:
- Title
- Abstract
- Introduction
- Case presentation
- Discussion
- Conclusion
- References
Let us discuss each component in detail:
1. Title
The title of a case report is typically the first thing to be read. Therefore, it should attract the attention of the reader and should also provide information regarding the subject of your case report. While writing a case report, you should refrain from using lengthy and irrelevant words in the title. Some of the words that should be avoided include “unique case,” “first report of,” and “review of the literature.”
An example of a brief yet comprehensive case report title is given below:
An Unusual Case of Intraabdominal Abscess After a Colonoscopy With Polypectomy
2. Abstract
The abstract is a brief, unstructured summary of the case report that provides an overall picture of the message conveyed in it. The main purpose of the abstract is to provide essential information about the case report, so that the readers can determine their level of interest in your case report. For most medical journals, the abstract for a case report generally has a word limit of 150 words or less.
See below for an example:
Diabetic ketoacidosis (DKA) with coexisting hypertriglyceridemia-induced acute pancreatitis is a rare yet potentially life-threatening condition. This report describes a patient with no history of diabetes who presented with DKA and coexisting acute pancreatitis secondary to severe hypertriglyceridemia. The patient did not respond to standard DKA management or plasmapheresis, developed acute respiratory distress syndrome (ARDS), and eventually expired.
3. Introduction
The introduction in a case report provides background information on the condition that you are describing, citing relevant literature where necessary. It lets the reader know why the case is worth reading and provides an explanation of the importance of the case in light of the previous literature. However, it is important to note that some journals, such as BJR Case Reports, do not require an Introduction section.
4. Case Presentation
This section is the focus of the case report and should include all relevant details in chronological order. You should avoid writing your own interpretations and inferences in this section. Tables and/or figures can be used here. Information regarding the following items should generally be provided in the Case Presentation section:
- Patient description and presenting complaints
- History of present illness, past medical history, medication history
- Relevant sexual, social, and family history
- Physical examination findings
- Diagnostic investigations, including imaging and laboratory tests
- Differential diagnosis
- Treatment plan
- Follow-up and actual outcome
5. Discussion
This is considered to be the most important section of a case report and should provide an in-depth interpretation of the key findings of your case. You should start off by expanding on the information provided in the Introduction section, followed by a summary of the existing literature. Describe the epidemiology of the condition being reported along with the different theories that explain its pathophysiology. The clinical features, physical examination findings, diagnosis, and treatment of the condition should also be described.
While writing the Discussion section, you should focus on comparing your case with already available literature and demonstrate how your case differs from previously published cases. You should also highlight the value that this new case adds to the current literature. In the last paragraph, you can also add a concluding statement that describes the lesson(s) learnt from the new case.
6. Conclusion
Some journals do not require you to write a separate Conclusion section at the end of your case report. In that case, the concluding paragraph of the Discussion section is all you need. However, other journals want you to end your case report with a conclusion or summary points. The Conclusion section should cover the key points of the case report and can include suggestions and recommendations for clinical practice or future research.
7. References
The references are listed at the end of the case report and serve as additional sources of information for the readers. These should follow the specific format for citing literature that is required by each journal. Different citation styles include AMA (American Medical Association), APA (American Psychological Association), MLA (Modern Language Association), and NLM (National Library of Medicine).
Here is an example of the AMA style, which is widely used for citing sources in medical research:
This was a brief overview of the general structure of a medical case report. If you would like to learn more about writing a case report or need help with a report writing project, please feel free to send me a message.