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How to Write a Case Report
Dr. Nancy Agnes, Head, Technical Operations, Pubrica, sales@pubrica.com
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)
.
I. 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.
II. 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.
III. 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)

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abstract/introduction, 2) case history/description, 3)
literature review, 4) discussion, 5)
conclusions/recommendations(3)
.
IV. 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.
V. 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.
VII. LITERATURE REVIEW
The organised literature search, similar to that
described for systematic reviews, is listed in the
methodology section for case reports. A well-

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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.
VIII. 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.
IX.SUMMARY/CONCLUSIONS/RECOMME
NDATIONS 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)
.
X. 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
XI. 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.