Instructions to write a case report

Writing a Case Report

Introduction

Writing a case report accurately and transparently is not easy. We provide online training in writing case reports at Scientific Writing in Health and Medicine (SWIHM) which includes access to CARE-writer, an online app that can be used to write case reports or case report preprints.

Tips that may help:

Know that it is easier to write the sections of a case report in a different sequence than the order in which the sections appear in a published case report.

First: Select a case and identify the message you wish to communicate, as well as your audience. Is this case report about an outcome, a diagnostic assessment, an intervention, a new or rare disease, or something else?

Second: Gather the necessary information to accurately write WHAT happened as a timeline and as a narrative. Create the timeline of your case report—a visual summary of WHAT happened in the case report (see examples of timelines that follow the CARE guidelines) before writing the narrative section.

Third: Complete the remainder of the case report using specialty-specific information if necessary with appropriate scientific references and explanations. Support WHY an outcome occurred with reference to the scientific and historic literature whenever possible. Write the abstract last.

De-Identification: Patient information must be de-identified and informed consent obtained prior to submitting your case report to a journal.

Writing Sequence

Part 1 — Working Title, WHAT happened: Timeline and Narrative

  1. Develop a descriptive and succinct working title that describes the phenomenon of greatest interest (symptom, diagnostic test, diagnosis, intervention, outcome).
  2. WHAT Gathers the clinical information associated with patient visits, in this case, report to create a timeline as a figure or table. The timeline is a chronological summary of the visits that make up the episodes of care from this case report.
  3. Narrative of the episode of care (including tables and figures as needed).
    • The presenting concerns (chief complaints) and relevant demographic information.
    • Clinical findings: describe the relevant past medical history, pertinent co-morbidities, and important physical examination (PE) findings.
    • Diagnostic assessments: discuss diagnostic testing and results, a differential diagnosis, and the diagnosis.
    • Therapeutic interventions: describe the types of intervention (pharmacologic, surgical, preventive, lifestyle) and how the interventions were administered (dosage, strength, duration, and frequency). Tables or figures may be useful.
    • Follow-up and outcomes: describe the clinical course of the episode of care during follow-up visits including (1) intervention modification, interruption, or discontinuation; (2) intervention adherence and how this was assessed; and (3) adverse effects or unanticipated events. Regular patient report outcome measurement surveys such as PROMIS® may be helpful.

Part 2 WHY it might have happened: Introduction, Discussion, Conclusion

  1. The introduction should briefly summarize why this case report is important and cite the most recent CARE article (Riley DS, Barber MS, Kienle GS, AronsonJK, et al. CARE guidelines for case reports: explanation and elaboration document. JClinEpi 2017 Sep;89:218-235. doi: 10.1016/jclinepi.2017.04.026).
  2. WHY it might have happened. The discussion describes case management, including strengths and limitations with scientific references.
  3. The conclusion, usually one paragraph, offers the most important findings from the case without references.

Part 3 — Abstract, Key Words, References, Acknowledgement, and Informed Consent

  1. Briefly summarize in a structured or unstructured format the relevant information without citations. Do this after writing the case report. Information should include (1) Background, (2) Key points from the case; and (3) Main lessons to be learned from this case report.
  2. Key Words. Provide 2 to 5 keywords that will identify important topics covered by this case report.
  3. Appropriately chosen references from the peer-reviewed scientific literature.
  4. A short acknowledgment section should mention funding support or conflicts of interest, if applicable.
  5. Informed Consent and Patient Perspective. The patient should provide informed consent (including a patient perspective) and the author should provide this information if requested. Some journals have consent forms that must be used regardless of the informed consent you have obtained. Rarely, additional approval (e.g. IRB or ethics commission) may be needed. The patient should share their perspective on the treatment(s) they received in one to two paragraphs. It is often best to ask for informed consent and the patient’s perspective before you begin writing your case report.
  6. Appendices (If indicated).

Instructions to write a case report