How To Write A Case Report?
– Dr Nupur Shrirao, Editorial for Oct 2021 Case Report special issue
A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Writing a case report represents your first effort at getting articles published in scientific journals and magazines. It is an easy and quick way to learn how to write ‘scientifically’ – and since it is easy and quick to read as well, it means your article will be read by a lot more dentists than research or review articles. Here I will be discussing how to write a good case report – I hope you try to write one as soon as you finish reading this!
How to select a case for the case report?
Every case is unique in a way, but every case cannot be reported. I am giving you some pointers on how to select a good case and ensure it gets published after all those writing efforts – the next time you go to your clinic, document the case if you observe any of the following:
- rare or unusual clinical conditions in a known disease
- a previously unreported or unrecognized disease
- unusual side effects to therapy/medication or response to conventional treatment
- unique use of imaging modalities or diagnostic tests to assist diagnosis of a disease
- illustration of a new theory/technique/material
- any case which questions a current theory/technique/material.
Remember that your selection of a case should fulfil one of these criteria:
- a source of new/clearer knowledge
- an important means for education and learning.
If your case does not fulfil one of the these criteria, drop the case. Don’t report a case which is already published repeatedly in literature – it amounts to redundant literature and holds no value.
Structure of a case report
Case reports are shorter than most other types of articles. They consist of the following six sections:
- an abstract
- an introduction with a short literature review
- a description of the case
- a discussion with detailed literature review
- a brief summary and conclusion of the case and
To enhance the case report’s flow and clarity, make sure you include some
- case pictures/instrument pictures/technique pictures/illustrations
An abstract is not compulsory, but it is always better if you give one. The abstract should summarize the case, the problem it addresses, and the message it conveys. Abstracts of case studies are usually short (preferably not more than 200 words) and unstructured (not subdivided into different headings but a single paragraph).
The introduction gives a brief overview of the problem that the case addresses, citing relevant literature where necessary. It should provide background information on why the case is worth reading and publishing. The introduction generally ends with a single sentence describing the diagnosis and treatment plan executed.
The case description or summary is the focus of the case report. The case should be best presented in enough detail for the reader to establish his or her own conclusions about the case’s validity.
The details of the case in the following order:
- Patient description – age, gender
- Case history – medical history, dental history, history of present illness
- Extraoral and intraoral examination results
- Results of X-rays and lab investigations, if any
- Treatment plan – expected outcome & actual outcome.
- Post operative instructions and follow-up .
This has to be written in a concise paragraph format, and not in a case history sheet format! 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.
Patient consent – 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. For minor patients, take parental consent and for disabled adults take the consent of closest family members.
Patient anonymity – Remember not to disclose any information that might reveal the identity of the patient. You need to be particularly careful with pictures, and ensure that pictures of the affected area do not reveal the identity of the patient (use of black strips on the eyes is recommended).
The discussion is the most important section of the case report. It interprets the key findings of the case report, contrasts the case report with what is already known in the literature to justify its uniqueness and draws clinically useful conclusions. This section should start by expanding on what has been said in the introduction, focusing on why the case is noteworthy and the problem that it addresses.
This should be followed by a summary of the existing literature on the topic. This part should describe the existing theories and research findings on the key issue in the patient’s condition. The review should narrow down to the source of confusion or the main challenge in the case. In comparing the new case with prior knowledge, you 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.
Finally, the case report should be connected to the existing literature, mentioning the message that the case conveys. The author should explain whether this corroborates with or detracts from current beliefs about the problem and how this evidence can add value to future clinical practice.
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. Here, the author can give suggestions and recommendations to clinicians, teachers, or researchers. This section should be concise and not exceed one paragraph.
See Highlights below for example
The references listed at the end of the case report should be carefully chosen by virtue of their relevance – quality over quantity, even 5-6 references are enough! Literature mentioned in the Introduction & Discussion sections must be mentioned sequentially here. You may also provide additional information for readers interested in more details. (like a ‘Further Reading’ section).
To conclude, I hope I have simplified the concept of a case report, enough for you to consider writing one! Consider the 6 articles mentioned in the highlights of this issue as examples of everything that I have written. You can email me your articles (or doubts) at email@example.com!
- Guidelines To Writing A Clinical Case Report. Heart Views. 2017;18(3):104-105.
- Writing a case report in 10 steps. BMJ 2015;350:h2693
- Volkland D, Iles RL. Guidebook to better medical writing. Washington, DC: Island Press; 1997.
- Morgan PP. Why case reports? CMAJ. 1985;133:353.
- Sun Z. Tips for writing a case report for the novice author. J Med Radiat Sci. 2013;60(3):108-113.