What is a Clinical Case Report?

A clinical case report is a detailed account of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. These reports typically describe an unusual or novel occurrence and are essential to medical progress, often introducing new ideas in medicine. Some case reports include a comprehensive review of relevant literature. They serve as a rapid, concise form of communication among busy clinicians who may not have the time or resources for large-scale research.

Reasons for Publishing a Case Report

The most common reasons for publishing a case report include:

1. An unexpected association between diseases or symptoms
2. An unexpected event during the observation or treatment of a patient
3. Findings that provide new insights into the pathogenesis of a disease or an adverse effect
4. Unique or rare features of a disease
5. Innovative therapeutic approaches
6. Variations in anatomical structures

Most journals publish case reports that address one or more of the following:

• Unusual observations
• Adverse responses to therapies
• Uncommon combinations of conditions leading to diagnostic confusion
• Illustration of new theories
• Challenges to current theories
• Personal impact on clinical practice

Structure of a Case Report

Different journals have slightly varied formats for case reports. It is advisable to review some case reports from the target journal to understand the general sequence and format. Typically, all case reports include the following components: an abstract, an introduction, the case details, and a discussion. Some journals may also require a literature review.

Abstract

The abstract should summarize the case, the problem it addresses, and the key message it conveys. It is usually very brief, preferably not exceeding 150 words.

Introduction

The introduction provides a brief overview of the problem addressed by the case, citing relevant literature. It generally concludes with a sentence describing the patient and their basic condition.

Case

This section details 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

Authors should ensure all relevant details are included and irrelevant ones are excluded.

Discussion

The discussion is the most critical part of the case report, convincing the journal of its publication worthiness. It should start by expanding on the introduction, highlighting the significance of the case and the problem it addresses. This section includes a summary of the existing literature on the topic, explaining current theories and research findings related to the patient’s condition. The review should focus on the main challenge or confusion in the case.

The discussion should connect the case to existing literature, explaining how it supports or contradicts current beliefs and how it can add value to future clinical practice.

Conclusion

A case report concludes with a summary or key points, depending on the journal’s format. This section briefly highlights the main points covered in the case report and may include suggestions and recommendations for clinicians, educators, or researchers. Some journals may not require a separate conclusion section, in which case it can be the concluding paragraph of the discussion.

Notes on Patient Consent

Informed consent is an ethical requirement for most studies involving humans. Before writing your case report, obtain written consent from the patient, as journals require it at the time of manuscript submission. For minors, parental consent is necessary. For adults unable to consent, consent from the closest family members is required. Patient anonymity is also crucial. Avoid disclosing any information that might reveal the patient’s identity, and ensure that any pictures used do not compromise the patient’s anonymity.