how to write a patient case report

by Alaina Hartmann 9 min read

How to write a patient case report - PubMed

17 hours ago Summary: The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion. The abstract of a patient case report should succinctly include the four … >> Go To The Portal


III. Patient case presentation
  1. Describe the case in a narrative form.
  2. Provide patient demographics (age, sex, height, weight, race, occupation).
  3. Avoid patient identifiers (date of birth, initials).
  4. Describe the patient's complaint.
  5. List the patient's present illness.
  6. List the patient's medical history.
Oct 1, 2006

Full Answer

How to write a report based on a case study?

  • The title should contain a phrase like case study or case report, so that readers understand what type of study it is.
  • An effective title might also say what condition the patient had, how it was treated, and whether the outcome was successful.
  • Most titles are less than 10 words long.

Can I write my own case report?

You can write a report and ask the judge to consider it, and if the circumstances are complex, probably should — same if the damages are composed of more than a few items, and you can attach receipts, etc. Remember, whatever you submit to the judge you must submit an exact copy to the other side, so you will need a total of three copies (one for yourself).

How to actually get your patients to write a review?

Are you posting a comment because:

  • You want to help others by providing genuine insights?
  • You are furious and feel the need to vent?
  • You are seeking revenge for a high bill or a canceled appointment?
  • You are a serial poster who simply likes posting across all social platforms?

Where can I publish a case report?

Tools to Use When Deciding Where to Publish

  • Jane (Journal / Author Name Estimator) Search for journals that might be interested in publishing your article. ...
  • Journal Citation Reports Weighs and ranks journals by a number of criteria. ...
  • Journal Citation Reports Quick Reference Cards Handout showing how to use JCR including definitions of various metrics and screenshots.

More items...

image

How do you write a patient case report Example?

This section provides the details of the case in the following order:Patient description.Case history.Physical examination results.Results of pathological tests and other investigations.Treatment plan.Expected outcome of the treatment plan.Actual outcome.

How do you present a patient case report?

Case Presentation. The case report should be chronological and detail the history, physical findings, and investigations followed by the patient's course. At this point, you may wish to include more details than you might have time to present, prioritizing the content later.

How do you write a simple case report?

Ten Steps to Writing an Effective Case Report (Part 1)Step 1: Identify the Category of Your Case Report. ... Step 2: Select an Appropriate Journal. ... Step 3: Structure Your Case Report According to the Journal Format. ... Step 4: Start Writing. ... Step 5: Collect Information Related to the Case.

How do you write a patient case study?

Throughout the whole writing process, you should support your case with evidence by citing information properly.Title.Abstract.Introduction.Client Characteristics.Examination Findings.Clinical Hypothesis/Impression.Intervention.Outcome.More items...

How do you start a case presentation?

How to Write a Case Study: a 4-Step FrameworkIdentify the Problem. Every compelling case study research starts with a problem statement definition. ... Explain the Solution. ... Collect Testimonials. ... Package The Information in a Slide Deck.

What are the components of patient case presentation?

Highlighted in this chapter are the essential components of the presentation: the chief complaint, the history of present illness (HPI), the past medical history, the family and social history, the review of systems, and finally, the physical examination findings.

How do I start writing a report?

Here are some steps to follow when writing a report:Decide on terms of reference.Conduct your research.Write an outline.Write a first draft.Analyze data and record findings.Recommend a course of action.Edit and distribute.

How do you start a report introduction?

The introduction should:discuss the importance or significance of the research or problem to be reported.define the purpose of the report.outline the issues to be discussed (scope)inform the reader of any limitations to the report, or any assumptions made.

What is the format of a report?

Reports are divided into sections with headings and subheadings. Reports can be academic, technical, or business-oriented, and feature recommendations for specific actions. Reports are written to present facts about a situation, project, or process and will define and analyze the issue at hand.

How do you start a patient case study essay?

Patient Status The first portion of the case study paper will talk about the patient — who they are, why they are being included in the study, their demographic data (i.e., age, race), the reason(s) they sought medical attention and the subsequent diagnosis.

What is an example of a case study?

Prospective case study methods are those in which an individual or group of people is observed in order to determine outcomes. For example, a group of individuals might be watched over an extended period of time to observe the progression of a particular disease.

What is required to submit a 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.

Why is it important to write a case report?

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.

What is a case report?

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.

Does CHM have funding for publication?

It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish. 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.

Do you need informed consent for a case report?

Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports. The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible).

Do journals have informed consent?

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.

Does HIPAA apply to case reports?

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 ...

How many paragraphs should a patient share their perspective?

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. Appendices (If indicated). Submission to a scientific journal.

What should be included in a short acknowledgement?

Acknowledgements. A short acknowledgements section should mention funding support or conflicts of interest, if applicable.

What is follow up and outcomes?

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.

How many paragraphs should a conclusion be?

The conclusion, usually one paragraph, offers the most important findings from the case without references.

Is it easier to write sections of a case report in a different sequence than the order in which the sections?

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.

Is it easy to write a case report?

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.

Can you submit a case report to a scientific journal?

Follow author guidelines and journal submission requirements when writing and submitting your case report to a scientific journal. You may wish to contact the journal before submitting your manuscript. (Download a partial list of journals that accept case reports.) Journals that do not explicitly accept case reports may publish case reports as components of other articles. Online training in writing case reports is available from Scientific Writing in Health and Medicine (SWIHM).

What is a case report?

A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine. Some reports contain an extensive review of the relevant literature on the topic. The case report is a rapid short communication between busy clinicians who may not have time or resources to conduct large scale research.

What is the conclusion of a case report?

A case report ends with a conclusion or with summary points, depending on the journal's specified format. This section should briefly give readers the key points covered in the case report. Here, the author can give suggestions and recommendations to clinicians, teachers, or researchers. Some journals do not want a separate section for the conclusion: it can then be the concluding paragraph of the Discussion section.

Why do we publish cases?

The most common reasons for publishing a case are the following: 1) an unexpected association between diseases or symptoms; 2) an unexpected event in the course observing or treating a patient; 3) findings that shed new light on the possible pathogenesis of a disease or an adverse effect; 4) unique or rare features of a disease; 5) unique therapeutic approaches; variation of anatomical structures.

Do you need informed consent for a case report?

Informed consent in an ethical requirement for most studies involving humans, so before you start writing your case report, take a written consent from the patient as all journals require that you provide it at the time of manuscript submission. In case the patient is a minor, parental consent is required. For adults who are unable to consent to investigation or treatment, consent of closest family members is required.

What is a clinical case report?

The clinical case report has been an integral part of medical literature throughout history. The oldest example of a preserved clinical case in medical literature is a text from an ancient Egyptian papyrus dating from the 16thto the 17thdynasty, 1600 BC, addressing the management of dislocated jawbone.[5] From Hippocratic case histories, “Epidemics” 400 BC, through Galenic case reports, in the second century AD, case reports were usually used to tell other doctors or colleagues about interesting cases they have encountered. Muslim scholars have reported case histories as well, particularly, Abu Bakr Mohamed Ibn Zakariya Al-Razi (865–929 AD), where he left a large collection of case reports in his 25-volume medical encyclopedia “Kitab Al-Hawi.”[5]

How to know if a case is appropriate for reporting?

Once you have a potential case, how would you know if this is an appropriate for reporting or not? Especially if you are a novice physician, once you encounter a possible case and you are suspecting if this patient fulfills one of those criteria which are described in Table 1. The first step is a high index of suspicion; keep your eyes open for every case, once you suspect a case then ask your colleagues either directly or in a group related to the same discipline, locally, to confirm that this could be a case report. The next step would be asking an expert from the national or international medical community about this case scenario, get their opinion and feedback, including the appropriateness of reporting this case. Once the feedback is positive, perform extensive literature search, through PubMed, Embase, Google Scholar, and databases for case reports to ensure that you retrieve all available information on this topic. Do not forget to look at popular case reports which are not indexed in PubMed and read through previously published case reports that will enhance your understanding of the subject and gives you a general scaffold to prepare your own report.

What is a case report?

The case report is a research design where an unexpected or novel occurrence is described in a detailed report of findings, clinical course, and prognosis of an individual patient, which might be, but not mandatory, accompanied by a review of the literature of other reported cases. Although case reports are considered the lowest in the hierarchy of evidence-based practice in the medical literature [Figure 1], it provides essential information for unfamiliar events and shared individual experiences, for better understanding and optimizing patient care. This approach might generate an idea or hypothesis, but it will not be confirmed unless we conduct further confirmatory quantitative experimental or observational study designs such as clinical trials or cohort studies. Despite that, case report provides the medical community with information which cannot be picked up by any other designs. Just to name a few, in 1819, James Parkinson published a case report entitled “An essay on the shaking palsy”[6] and lead to the discovery of Parkinson's disease. And in 1981, a case report was published in the literature as “Preliminary communication on extensively disseminated Kaposi sarcoma in a young homosexual man”[7] few years later, HIV from this case report was discovered. Furthermore, in 2012, Ali Zaki reported an article in New England Journal of Medicine titled “Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia” which ultimately, lead to the discovery of Middle East Respiratory Syndrome Coronavirus.[8] All those previous examples show how important is case report in the advancement of medical practice. The case report might be in the tail of the hierarchy of evidence-based medicine but if properly selected and appropriately reported it might stand a better chance of publication in high impact journals than even a clinical trial.

How many authors are allowed in a book?

2. Authors name: Should not exceed more than six authors

How many words should a case report be?

The word count for case report may vary from one journal to another, but generally should not exceed 1500 words, therefore, your final version of the report should be clear, concise, and focused, including only relevant information with enough details.[3] If a shorter version is required by the journal, then you can always edit or trim off the discussion section of your article. The general format adopted for most case reports is detailed in the following subsection and summarized as a checklist in Table 2.

How long to wait to write a case report?

Give the case an appropriate time frame in the course of the disease to observe the development over time. Wait for 6 months during multiple visits, before you start writing a case report to allow adequate time to complete the clinical course.

Why is case report important?

Case report, as a research design, describes important scientific observations that are encountered in a clinical setting to expand our knowledge base. Preparing a case report is far easier than conducting any other elaborative research design. Case report, with its main components, should be focused and delivers a clear message. In this article, the key components of a case report were described with the aim of providing guidance to novice authors to improve the quality of their reporting.

What is a case report?

Case Report: A Beginner’s Guide with Examples. A case report is a descriptive study that documents an unusual clinical phenomenon in a single patient. It describes in details the patient’s history, signs, symptoms, test results, diagnosis, prognosis and treatment.

How does a case report affect us?

In his book Against Empathy: The Case for Rational Compassion, Paul Bloom explains how a powerful story affects our emotions, can distort our judgement and even lead us to make bad moral choices.

What happened to Gage after the accident?

After the accident, Gage became profane, rough and disrespectful to the extent that he was no longer tolerable to people around him . So he lost his job and his family.

Why are case reports important?

Case reports are great to get first impressions that can generate new hypotheses (e.g. detecting a potential side effect of a drug) or challenge existing ones (e.g. shedding the light on the possibility of a different biological mechanism of a disease).

Why do we need case reports?

Case reports offer, in general a fast, easy and cheap way to report an unusual observation or a rare event in a clinical setting, as these have very small probability of being detected in an experimental study because of limitations on the number of patients that can be included.

When a case report describes a rare event, it is important to remember that what we’re reading about is?

When a case report describes a rare event it is important to remember that what we’re reading about is exceptional and most importantly resist generalizations especially because a case report is, by definition, a study where the sample is only 1 patient.

Which type of report has the lowest level of evidence?

Because of these limitations, case reports have the lowest level of evidence compared to other study designs as represented in the evidence pyramid below:

image

Abstract

Format of The Patient Case Report

  • Case reports should encompass the following five sections: an abstract, an introduction and objective with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion.6,7 Supplementary parts such as tables, figures, graphs, and illustratio...
See more on academic.oup.com

Summary

  • Patient case reports are valuable resources of new and unusual information that may lead to vital research and advances in clinical practice that improve patient outcomes. Case reports should contain an abstract and four sections—an introduction, case presentation, discussion, and conclusion. The introduction provides the subject, purpose, and merit of the case report and the …
See more on academic.oup.com

Conclusion

  • Patient case reports are valuable resources of new and unusual information that may lead to vital research.
See more on academic.oup.com

Appendix A—Criteria For Publishable Case Reports

  • Publishable patient case reports include cases that: 1. Advance medical science and spawn research; 2. Describe rare, perplexing, or novel diagnostic features of a disease state; 3. Report therapeutic challenges, controversies, or dilemmas; 4. Describe a new surgical procedure; 5. Report how a drug can enhance a surgical procedure; 6. Teach humanistic lessons to the health …
See more on academic.oup.com