Instructions for creating the basic narrative used to describe
a case study (1- 5 patients)
HEY! when writing up your report refrain from using identifying data, such as date of birth, date of service, patient name/initials or medical record number. Do not use case when referring to a person - a case is an instance of disease, a patient is a person.
TITLE
Descriptive title of the case report/series; keep it tight, no 100 word titles.
INTRODUCTION
The introduction should be brief; tell why the case is important and why it is being reported. Case studies usually respond to one of the following generic topics but use specific information from the case being presented.
- An unexpected association between diseases or symptoms
- An unexpected event in the course of observing or treating a patient
- Findings that shed new light on the possible pathogenesis of a disease or an adverse effect
- Unique or rare features of a disease
- Unique therapeutic approaches
SIGNIFICANCE/UNIQUENESS OF CASE
Using the literature, establish any previous work that is related to your research question. Make clear to your reader whether this is the first ever reported, or how many have been reported previously. The essential characteristic of a publishable case report is educational value. After all, nobody is going to change the way they practice medicine based upon one case report. In addition, it is not true that a report must tell of a unique finding. Some case reports are published because they support the findings in previously published cases or because they are useful reminders of an important point in diagnosis or treatment.
PATIENT DESCRIPTION
Describe the patient, including gender, age, height, weight, BMI, social history (including tobacco and alcohol use), use of illegal substances, medication being used, notable results of physical examination and laboratory tests, and differential diagnosis or diagnoses considered, just to name a few. When in doubt, think about the patient information you would like to know as background information and provide it in this section. Don’t go overboard; we don’t need to know how many toilets are in the patient’s primary residence. Give all of the basics and add the specifics important to the case.
INTERVENTION
Describe all therapeutic interventions conducted during the course of treatment. Only provide the results of relevant examinations and laboratory tests, usually those with positive results. List the laboratory's ranges of normal values for any unusual tests performed.
RESPONSE TO TREATMENT
Describe the outcome of treatment including final diagnosis.
DISCUSSION
The purpose of the discussion is to explain anything that isn't clear in the case description and to offer interpretations of findings. It’s also the spot to indicate why the intervention used for your case was different from similar cases reported previously. Make clear any important point that isn't explained in the case descriptions. For example, if you reported that liver enzymes were elevated but no significant liver dysfunction was found, tell the reader in the discussion section why the enzymes were elevated. Also discuss implications for the field.
CONCLUSIONS
The big finish, where you get to blow your audience away with your final, pithy comment. This should be brief, three sentences tops. If you’re at a loss for words, you can either do a combined Discussion/Conclusions section, or just do a conclusions section that reiterates the importance of your case.
OTHER REQUIREMENTS
- All case reports must have approval before being presented outside of the institution.
- Case report submission requirements:
- Spectrum Health
- Saint Mary's Health Care
- If you are using a photo with identifying features (e.g., face, tattoo, birthmark), you must have written approval from the patient (contact the GRMERC Research Department for appropriate form).