from diagnosis to disclosure: present your medical cases

Case reports typically center around diseases, unusual clinical presentations, or uncommon complications or events. From a technical perspective, a case report qualifies as a scientific study characterized by the smallest possible sample size, often denoted as an “n = 1.” This emphasis on individual cases allows for detailed exploration and documentation of unique and noteworthy clinical scenarios, contributing valuable insights to medical literature despite the limited sample size. A case series is a form of observational study that presents multiple patient cases with the same presentation/diagnosis and/or treatment.

Writing a clinical case report/case series involves presenting detailed information about a specific patient’s medical condition and treatment. Here are general guidelines to help you structure and write an effective clinical case report/case series:

1. Steps to take before writing a case report

1.1. Obtain the consent from patient

The relationship between a clinician and a patient is intensely personal as well as professionally structured. Even beyond what is required by federal law, patients approach healthcare providers with the ethical presumption of privacy and confidentiality. Patients with uncommon conditions or complications (as well as their families) can frequently recognize themselves from a case report, even after identifying information has been removed. This is true even when strangers cannot. For this reason, patient consent is required.

1.2. Discuss with the treating clinicians

It is advisable for writers to consult with other healthcare providers involved in the patient’s care prior to writing a case report. Some authors will only let other clinicians know that a case report is being thought about; however, depending on the interest and interprofessional dynamic, it might be appropriate to ask for permission or even extend invitation to co-author. To prevent disagreements or hurt feelings in the future, it is usually preferable to address these issues before academic work starts.

1.3. Build your team

Assemble the group of supporters and colleagues who will help you write the case report before you start writing. This could include more seasoned medical professionals who can help you with the case’s clinical aspects, academics who can assist you with a literature review, and/or co-authors and editors who can assist you with drafting and submitting your manuscript.

1.4. Gather all clinical information

Extensive descriptions of the patient’s presentation and clinical trajectory are necessary for case reports. Numerous data points are included in this, such as a thorough medical history, physical examination, lab results, imaging, and significant incidents and results. Make sure you have access to a comprehensive medical record that contains all the information needed to write a thorough case report before committing to writing one. This could entail getting the patient’s medical records from other doctors or even following up with them. Perform a literature review: Review the existing literature on the subject matter of your case study. Should your patient have a specific disease, that should be the main topic of the literature review. Background information on common diseases should be included if you are focusing on an unusual presentation of a common disease. However, your attention should be drawn to atypical presentations, including those that are pertinent to your patient. Basic details about the procedure and its complication rates should be included in your research if you choose to concentrate on a particular procedural complication. A case study’s literature review is a condensed form of a comprehensive literature review, and it is not required to contain every pertinent article that has ever been published. However, it should be a thorough review that is carried out using an academic search engine (such as OVID, MEDLINE, etc.) and should concentrate on original, high-quality sources. 

After completing these steps, you can move on to the rough draft of your manuscript.

2. Components to be included for writing patient case reports

2.1. Title

  • The title of an article plays a pivotal role in capturing the attention of reviewers, editors, and readers, prompting them to delve into the entire content.
  • Authors are encouraged to craft a concise and compelling title that conveys a clear idea of the article’s contents, avoiding vagueness and non-specific terms.
  • The title should reflect the new message of the article, showcasing its scientific significance.
  • Authors should steer clear of unnecessary abbreviations and eschew the use of superfluous words.
  • A well-thought-out and comprehensive title not only enhances the article’s appeal but also ensures scientific soundness, contributing to the overall effectiveness of research communication.

2.2. Abstract

  • Including an abstract facilitates easy retrieval from electronic databases and aids researchers in gauging their interest levels in the case report.
  • The abstract should encapsulate the four main sections of the main text—introduction and objective, case presentation, discussion, and conclusion.
  • However, the format may vary based on the specific style guidelines of the journal if submitted for publication.
  • The abstract serves as a succinct preview of the case report, providing key insights into the study’s purpose, case details, discussion points, and ultimate conclusions.

2.3. Introduction

  • The introduction in a case report should be concise and immediately capture the reader’s attention and interest.
  • It serves to provide background information on why the case is noteworthy for reading and publishing, explaining the case report’s focus, for instance: “We present/report a case of ….” The merit of the case report must be justified in relation to existing literature.
  • Therefore, a focused and comprehensive literature review is necessary in this section to support the author’s claim.
  • It is essential to note that a more detailed literature review belongs in the discussion section, even though critical evaluation of the literature is still required.

2.4. Case presentation

  • The Case Presentation section is the substantial core of a case report, providing a systematic description of the patient’s presentation.
  • It follows a structure akin to common medical documentation, derived from the patient’s medical records.
  • The Case Presentation should be organized into individual sub-sections, meticulously covering the following aspects:

History: The History section in a case report delineates the subjective components of the patient’s history of present illness (HPI), encompassing pertinent past medical, surgical, and social history. It should meticulously capture all relevant positive and negative details, with keen consideration of the differential diagnosis and final diagnosis. Extra attention should be given to presenting the chronological order of events and temporal relationships to ensure clarity for the reader. Recognizing that timing is crucial, the section aims to construct a narrative that allows the reader to follow the patient’s story with precision.

Physical Exam: The Physical Exam section of a case report focuses on presenting the objective findings derived from the patient’s physical examination. This section should commence with vital signs and be systematically organized by the body system. It is imperative to include relevant positive and negative findings, with thoroughness in detailing the systems most pertinent to the differential and/or final diagnosis. By organizing the information in this manner, the Physical Exam section provides a clear and structured account of the clinical observations made during the examination.

Diagnosis: The Diagnostics section of a case report encompasses all pertinent diagnostic tests conducted by the medical team(s) and their corresponding results. This comprehensive compilation includes laboratory tests, imaging studies, and other diagnostic modalities. In instances where patients undergo extensive workups, authors have the discretion to streamline this section, focusing on the tests most relevant to the differential and/or final diagnosis. By presenting this information, the Diagnostics section provides readers with a detailed overview of the diagnostic journey undertaken during the case.

2.5. Case management

       Including the following sections:

Treatment/Intervention: This section provides a detailed account of any treatments or interventions administered to the patient as they occurred in real life. It can be presented as a standalone section or integrated into the Clinical Course/Outcome section, depending on the narrative flow of each individual case.

Clinical Course/Outcome: The Clinical Course or Outcome section(s) delineates the patient’s response to treatment or intervention, if applicable. It comprehensively narrates all pertinent clinical events and outcomes, offering a chronological account of the patient’s hospital course for those who are hospitalized. This includes additional tests, procedures, interventions, and complications. In cases of outpatient or discharged patients, the section may incorporate information obtained through follow-up appointments or communications. The Clinical Course/Outcome section plays a pivotal role in providing a holistic view of the patient’s journey from treatment initiation to the ultimate resolution or ongoing management.

2.6. Discussion

  • Every case report should incorporate a robust Discussion section following the case description.
  • The academic and educational merit of case reports is predominantly derived from the quality of the Discussion section.
  • Authors are encouraged to dedicate sufficient time and effort to ensure this section adheres to high academic standards.
  • The content within the Discussion section is primarily derived from the author’s literature review, and all statements should be substantiated with appropriate references.
  • The Discussion section can be structured with the following sub-sections to enhance organization and flow:

Epidemiology: This segment of the discussion contextualizes the case within an epidemiological framework. It typically includes the incidence and prevalence of the disorder, if known, and delineates the characteristics of the population in which it is commonly observed. References can be drawn from original research articles, review articles, or other case reports and case series. If there is no prior record of a similar case in the medical literature, the article should explicitly state so in this section.

Pathophysiology: The Pathophysiology section succinctly describes the underlying pathological processes of the disease or condition or elucidates the mechanism of an iatrogenic complication if relevant. In case reports, this section should be concise, focusing on clinically relevant elements of pathophysiology whenever possible.

Diagnosis: This section outlines the typical elements of a patient’s history, examination, and diagnostic work-up used for making the diagnosis. It includes discussions on gold standard tests, when applicable. The focus should be on the typical work-up of a disease, not necessarily the specific work-up presented in the case report. Differences between a typical presentation/work-up and the one described in the case presentation can be highlighted.

Management: The Management section concentrates on the standard of care for the disease or condition if one exists. It may choose to compare with the case presented, providing insights into variations from the typical standard of care.

Prognosis, Prevention, or Other Implications: This segment addresses additional pertinent information to educate readers on fundamental principles. It may include discussions on the typical prognosis, natural history, or clinical course of the disease, especially to provide perspective on the clinical course of the presented case. Prevention strategies, particularly for complications of diseases or procedures, may also be discussed.

2.7. Conclusion

  • The Conclusion section transcends mere summarization, offering final messages, recommendations, or parting wisdom.
  • Authors may discuss broader implications of the case, challenges faced by a specific patient population, or increased awareness clinicians should have about a particular disorder. The Conclusion serves to provide a thoughtful and impactful closure to the article.

2.8. References

  • This section, often titled “References,” compiles a list of all the sources cited in the review article text, figures, or tables.
  • Use a consistent citation style throughout your review.
  • Proper citation style ensures uniformity and facilitates readers’ ability to locate and verify the sources.
  • The formatting of these references should adhere to APA style.

For Example

Journal Articles Gal, A., & Burchell, R. K. (2023). Diabetes Mellitus and the Kidneys. Veterinary     Clinics of North America: Small Animal Practice, 53(3), 565-580.
Books Sapra, A., & Bhandari, P. (2023, June 21). Diabetes. In StatPearls. Retrieved from StatPearls Publishing; 2024 Jan. Medley, D. M. (1983). Teacher effectiveness. In H. E. Mitzel (Ed.), Encyclopedia of educational research (Vol. 4, pp. 1894-1903). New York: The Free Press.
Conferences/meetings Whipple, W. S. (1977, January). Changing attitude through behavior modification. Paper presented at the annual meeting of the National Association of Secondary School Principals, New Orleans, LA. (ERIC Document Reproduction Service No. ED146500)
Annual Reports American Psychological Association. (2008). Electronic resources. Retrieved June 17, 2008 from http://www.apastyle.org/elecref.html.
  • Identifying the most important references is a somewhat subjective process, but many researchers use article-level metrics to pinpoint the key papers in a research area.
  • As you retrieve and read relevant references, list them in your outline under the appropriate subheading and make notes to keep track of key findings, strengths, weaknesses, controversies and quotes that might be included in your review.
  • Although the reference list supporting an article is usually positioned at the very end, this section should never be considered an afterthought, and you should build your bibliography as you work.
  • There are many reference management tools available to assist in organizing references, ranging from freely available tools such as Zotero to commercial software such as Endnote.
(https://en.wikipedia.org/wiki/Comparison_of_reference_management_software)

3. When Author disagrees with a reviewer’s comments

When an author disagrees with a reviewer’s comments, it’s essential to approach the situation constructively. Here are some steps to navigate disagreements:

Stay Calm and Objective:

  • Authors may feel defensive, but remaining calm and objective is crucial.
  • Avoid taking comments personally; remember that the goal is to improve the manuscript.

Analyze the Feedback:

  • Carefully review the reviewer’s comments.
  • Consider whether the feedback is valid and whether it aligns with the manuscript’s goals.

Seek Clarification:

  • If a comment is unclear or seems contradictory, seek clarification from the reviewer.
  • Politely ask for specific examples or further explanation.

Provide a Thoughtful Response:

  • Address each comment individually.
  • Acknowledge valid points and explain any areas of disagreement.
  • Provide evidence or rationale for your perspective.

Propose Revisions:

  • Suggest revisions that address both the reviewer’s concerns and your own perspective.
  • Be open to compromise and find common ground.

Use the Cover Letter:

  • In your response to the editor, use the cover letter to explain your revisions.
  • Highlight changes made based on reviewer feedback and provide context for any disagreements.

Remember the Purpose of Peer Review:

  • Peer review aims to improve the quality of the manuscript.
  • Even if you disagree, consider whether the suggested changes enhance the work.

Be Professional and Grateful:

  • Maintain a professional tone in all communications.
  • Express gratitude to the reviewer for their time and insights.

Remember that respectful dialogue between authors and reviewers contributes to the scholarly process. Ultimately, the goal is to enhance the manuscript and contribute to scientific knowledge.