Address for Correspondence: Dr. Nada Mansour Abdulhaq, Department of Pediatric, King Abdulaziz University, Rabigh Branch, P.O Box: 50891, Jeddah 21533, Saudi Arabia. E-mail: moc.liamg@41rotcodlufecaep
Received 2018 Dec 24; Accepted 2019 Jan 1. Copyright : © 2019 Urology AnnalsThis is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Research is an important competency that should be mastered by medical professionals. It provides an opportunity for physicians to develop numerous skills including communication, collaboration, time management, and teamwork. 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.
Keywords: Case report, education, guideline, publication, research, writing“The best teaching of medicine is that taught by the patient himself” is a famous statement by William Osler which describes the opportunities we have as physicians to learn from our encounters with patients.[1] This learning experience, based on the observation of clinical cases, can be transferred to others, locally, nationally, and internationally, through communication and reporting. A case report is the first effort for many doctors, and other health professionals to convey a message to the entire medical profession by the means of specialized journal and remain essential to the art of medicine.[2] The purpose of the case report is to expand our knowledge on clinical manifestation, diagnostic approach, or therapeutic alternative of a disease, ultimately, to improve the quality of care provided to our patients. A case report that is worth reading should, therefore, contain both practical and educational messages.[3,4]
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 16 th to the 17 th dynasty, 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]
Those case histories were not a publication but rather a documentation or a message between the medical professionals, and it is usually kept in their records. Case reports have now been developed and accepted as a scholarly publication to disseminate knowledge to a wide medical audience.
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.
Hierarchy of evidence base medicine
Some scientist classifies case reports as a qualitative study design, others might consider it a quantitative approach or even a mixed method design.[9] This polarization of the case report is unfair. However, if we have to categorize it; when we consider all research approaches in medicine, it can be classified into exploratory or confirmatory; then, case reports definitely will be considered an exploratory research approach. Case report can be classified as a single case report, two case reports or case series, which aggregate more than two cases in a report. Case reports are usually retrospective by nature, however, it can be prospectively designed, for example, applying a new diagnostic or management approach or guideline of a particular health condition to discover new cases.[10]
Cases deemed appropriate for a publication are listed in Table 1 .[3] Despite these restrictive criteria, any case report could have a reasonable chance of publication even if it was not novel, as long as it was authentic, lead to an incremental advance in medicine or carries an educational value.
Criteria for published case report
| Unreported side effects |
| Unusual side effect |
| Adverse interactions involving medications |
| Unexpected or unusual presentation of a disease |
| New associations or variations in disease process |
| Presentations, diagnosis, and/or management of new and emerging diseases |
| Unexpected association between disease 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 |
The source of case reports is clinical setting, every single patient is a potential case report therefore, always keep an eye on unusual cases in your practice either in the ward or in the clinic. Once a potential case is identified, and the patient is in hospital, follow him through hospitalization until discharge. 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.
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.
Once the decision was made to report this case, obtain an informed consent from the patient; otherwise, it will not be accepted for publication. Moreover, take a permission from consultant in-charge of the case before writing your report.
Once you have reviewed the literature and improved your knowledge on the topic, use the patient's note to record the key points in history, examination findings, relevant data results and interpretation, treatment (including operational findings), and outcomes. Delete all patients’ personal information, identifiers or contact detailed from the prepared report, including the radiological or histopathological images before you copy them into your article. Save the prepared report on a password protected hospital computer.
The last step would be checking the journal which is most appropriate for your case report. Those journals provide you with the required criteria and appropriate format to prepare your report, to enhance their acceptability for publication. Many journals are interested in published case reports, but not all. In 2007, the first case report journal was created “Journal of Medical Case Reports” since then, the interest raised and many other journals dedicated for case reports were created including a specific database for all case reports are aggregated and continuously updated from several publishers.[3]
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 .
Checklist for writing a case report
| Topic | Item description |
|---|---|
| Title page | 1. Title: “case report” should be added in the title |
| 2. Authors name: Should not exceed more than six authors | |
| 3. Affiliation: The names of organizations for each author | |
| 4. Corresponding author: Write the full name of the corresponding author and all contact details including email and mobile number | |
| Abstract | 5. Background: what does this case report add to the medical literature? |
| 6. Case summary: chief complaint, diagnosis, intervention, and outcome | |
| 7. Conclusion: what is the main “take-away” lesson from this case? | |
| Keyword Introduction Patient information | 8. 4-7 key words-include “case report” as one of the key words |
| 9. Briefly summarize the background and context of this case report (1-2 paragraphs) | |
| 10. De-identified demographic and other patient or client specific information | |
| 11. Chief complaint | |
| 12. Relevant history including past surgeries, family history, and medication history | |
| Physical examination Diagnostic assessment | 13. Relevant physical examination findings |
| 14. Evaluations such as laboratory testing and imaging | |
| 15. Diagnostic reasoning including other diagnosis considered and challenges | |
| 16. Consider tables or figures linking assessment, diagnosis and interventions | |
| 17. Prognostic characteristic where applicable | |
| Interventions | 18. Intervention type |
| 19. Intervention detailed methods and duration | |
| 20. Explanation to intervention outcome | |
| 21. Other concurrent interventions | |
| Follow-up and outcomes | 22. Clinician assessment |
| 23. Important follow-up diagnostic evaluations | |
| 24. Assessment of intervention adherence and tolerability, including adverse events | |
| Discussion | 25. Strengths and limitations in your approach to this case |
| 26. Compare your results with previous reported cases (optional) | |
| 27. Specify how this case report informs practice or guidelines | |
| 28. How does this case report suggest a testable hypothesis? | |
| Conclusion | 29. State clearly the main conclusion of the case report and provide a concise statement and explanation of the importance and relevance |
| Patient perspective Informed consent Additional information | 30. When appropriate report the patient experience in his own word and his message |
| 31. Informed consent from the person who is the subject of this case report is required by most journals | |
| 32. List of abbreviation | |
| 33. Competing interest | |
| 34. Author contribution | |
| 35. Author information | |
| 36. Acknowledgement and | |
| 37. References | |
| Plagiarism Supplementary material | 38. Check for plagiarism |
| 39. Table: Use Microsoft word, avoid creating tables using spaces or tabs, expand all abbreviations in the legend. Each table must be submitted as a separate file | |
| 40. Figures: Number each consecutively, expand all abbreviations in the caption. Each figure must be submitted as a separate file | |
| 41. Images: Digital images must be high resolution, JPEGS all images must be cited in the text and numbered in order of appearance | |
| 42. Cover letter |
This is the most commonly read part of your article; therefore, it should be relevant, concise, informative, descriptive, and appealing enough to attract readers to your report. It is placed in the first page of the manuscript, but some journal might request you to specify a separate file from the manuscript, labeled as a “title page” file. In preparing the title, avoid unnecessary words, wordplay, double meaning, cute wording, and never uses abbreviations in the title. It is always advisable to add “case report” in your title. Beneath the title, list all authors and their affiliations on the same page including their E-mails account. Most of the case reports are not prepared by a single author, but it should not exceed more than six authors; otherwise, the journal might not accept your case report for publication. Finally, under the subsection of corresponding author, assign one author to communicate with the journal and include all details of communication, such as institutional address, E-mail, and phone numbers.
Who should be the corresponding author? Any person who will submit the article to the journal to get the feedback from the editor of the journal and should be one of the article's authors.
It is the most important part of your article as it will be freely accessible for others to read when retrieved from any medical databases during the relevant search. However, it is the last part written in your article. It should include a brief summary that gives a general idea of the content of the case report. It should not include any references or abbreviations and should not exceed 350 words, preferably
This is quite important for indexing your article, and it should be from three to ten words, and you should be very careful in your selection, as it would help in retrieving your paper during the search.
In this section, the definition and brief description of the pathology, including common presentations and disease progression is discussed, explaining the background of the selected topic. Followed by a brief description of what is about to be reported and the importance of reporting such case. The content should be clear, focused, concise, and attract the reader's attention and interest.
Provide a clear picture of the patient's condition and presentation, and it is best presented in chronological order with sufficient detail and explanation. Describe the relevant demographic information of the patient censoring any details that could lead to the patient being identified. Start with the current medical condition and primary complaint with detailed history including relevant family history, occupational and social history, medication, and allergy. Findings of physical examination should be briefly reported with all relevant investigation, laboratory results and images, and its analysis. Describe the differential diagnosis and the rational of the management approach, including follow-up results and final diagnosis. Avoid any extensive interpretation or defense for the approach you took. This section can be broken up into small subsections if needed, and it should be supplemented with necessary images and tables to facilitate reader's understanding of the case.
Probably, this is an optional section, but it is preferable if reported, as it would explain more of your rational and approach with added additional relevant information about the uniqueness of this case. Compare your findings with what is known in the literature and why you think this case is different. Only discuss what is relevant to your case and do not provide any unproven and unsupported speculation. Acknowledge and explain any ambiguity or unexpected features occurred even if it is contradicting your concept. Explain how this case would contribute to the literature and suggest justifiable recommendations.
The section should include a concise and brief statement, explaining the importance and relevance of your case and it should relate to the purpose of the paper.
This new section is an optional, but it adds a new dimension to your paper, as it gives the chance to patients with their own perspective to write and describe their experiences throughout the disease process. Make sure that any patient's identifiers are removed, and his identity is managed appropriately with confidentiality, removing all irrelevant information to the case report.
Before submission, make sure that the patient gave his informed consent for publication, and statement indicating that should be clearly narrated in the report. You do not need to send the consent form on submission, but it should be available if requested. In case of the child, the parent or legal guardian should be consented instead, and if the child is a teenager then both patient and his parent should be consented. Many journals will not proceed with the peer review process unless a statement like “written informed consent was obtained from the patient for publication” is clearly stated. This statement could be in a separate section, as indicated here, or within the content of the report. If the patient is incapacitated or deceased, obtain the consent from the next-of-kin, and this should be stated clearly in the report. If the patient is deceased and next-of-kin is unreachable, you should exhaust all reasonable attempts to obtain the consent. If you fail, then you should state that in your report. If the patient is still alive but unreachable and you did not obtain the consent, do not bother publishing the case.[3]
In this mandatory part, all authors should disclose any financial competing interest. If none, then, a statement like “the authors declare that they have no competing interests” should be clearly stated.
In this section, you need to credit all individuals who made a substantial contribution to the production of this study. Criteria of qualification to be an author should be strictly followed and explicitly stated for each author, separately. The first criterion is being a part of the conceptual development, data acquisition or analysis, then involvement in drafting part of the manuscript, and finally approving the final version of the manuscript. If those criteria are not fulfilled, then those individuals should be acknowledged in the next section. Be cautious from excessive authorship as this might lead to rejecting your article.
You need to mention around 15 references if possible, and few of them should be within the past 5 years, but do not exceed more than 25 references.
This is an optional supplementary document, addressed to the editor-in-chief, in a formal letter. Explain why this report is important and why it should be published in this journal.
Writing a case report varies from one physician to another, depending on the expertise of the author who prepared the report. This variation is influenced by many factors ranging from the author's knowledge base to his writing skills. The Peer review process will detect this variation to assure the quality of reporting through critical appraisal. It will assess the report, provide a valuable, supposedly constructive, feedback and helps the editor in a decision regarding the publication. This assessment should be as objective as possible to reach an unbiased decision. Therefore, several schemes were formulated to evaluate the quality of the case report. One of which is the Piersons 5-component scheme which relays on five major components, each component is scored from 0 to two, with a possible total score of 10 and lowest score of zero. The five major components are uniqueness, documentation, interpretation, objectivity, and educational value.[11] If the calculated score is more than 8, then this report is worth publishing. A score from 6 to 8, indicate possible publication with caution about validity. Any score
Matrix of case report evaluation
| Components | Points | ||
|---|---|---|---|
| 0 | 1 | 2 | |
| Documentation | Insufficient data provided with incomplete references for documentation | Most information is available with some missing data, images and references | Information is complete and accurate with supplemented with enough images and tests with relevant references |
| Uniqueness | Well reported and documented in the literature | Reported before but not in the same field or journal or few cases | It was never reported before |
| Educational values | Case is incomplete with weak instructional content, and irrelevant outdated references | Case described missing, atypical or contradictory feature with incomplete discussion of the topic and less ideal references | Complete description with appropriate and comprehensive discussion on selected topic which provides an opportunity to learn |
| Objectivity | Clear selective reporting, author’s bias toward the subject matter is evident with insufficient or inadequate presentation and reporting the evidence supporting the author’s idea only | Data are presented in appropriate format but uncertain completeness, with selective or subjective reporting. Contradicting theories are omitted with incomplete references of those opposing to the authors | All data is complete with appropriate format and no evidence of selective reporting. All alternative explanation is discussed, and atypical features are presented. No evidence of author advocacy or bias related to conflict of interest |
| Interpretation | Extrapolation of conclusions about mechanisms or interventions well beyond the data presented | Some conclusions went further than what is acceptable of the data presented | Conclusions and recommendation were conservative, compatible with the data provided |
The calculated total score: Score of 9-10: Excellent report and most likely will add new information to the medical literature, Score of 6-8: Can be published but reader should be caution of validity and clinical value, Score of 5 or Less: Report is considered inadequate and inappropriate for publication
Case report remains an important source of information and common method in knowledge dissemination among physicians due to its simplicity in design. It will continue providing new research ideas through hypotheses generation. Finally, as I commenced my article with William Osler, I will end by quoting his other famous statement…. “Always note and record the unusual…. Publish it, place it on permanent record as a short, concise note. Such communication is always of value.”
There are no conflicts of interest.
You need to mention and acknowledge the source of the research fund if any. Moreover, acknowledging all people who helped you, supervised you, or assisted you in finalizing this report, if they are not fulfilling the criteria to be an author.
1. Jenicek M. Clinical case Reporting in Evidence-Based Medcine. Hamilton (ontario) and Montreal (quebec): Canada Butterworth Heinemann. 1999 [Google Scholar]
3. Rison RA. A guide to writing case reports for the journal of medical case reports and bioMed central research notes. J Med Case Rep. 2013; 7 :239. [PMC free article] [PubMed] [Google Scholar]
4. DeBakey L, DeBakey S. The case report. I. Guidelines for preparation. Int J Cardiol. 1983; 4 :357–64. [PubMed] [Google Scholar]
5. Nissen T, Wynn R. The history of the case report: A selective review. JRSM Open. 2014; 5 :1–5. [PMC free article] [PubMed] [Google Scholar]
6. Parkinson J. An essay on the shaking palsy 1817. J Neuropsychiatry Clin Neurosci. 2002; 14 :223–36. [PubMed] [Google Scholar]
7. Gottlieb GJ, Ragaz A, Vogel JV, Friedman-Kien A, Rywlin AM, Weiner EA, et al. A preliminary communication on extensively disseminated Kaposi's sarcoma in young homosexual men. Am J Dermatopathol. 1981; 3 :111–4. [PubMed] [Google Scholar]
8. Zaki AM, van Boheemen S, Bestebroer TM, Osterhaus AD, Fouchier RA. Isolation of a novel coronavirus from a man with pneumonia in Saudi Arabia. N Engl J Med. 2012; 367 :1814–20. [PubMed] [Google Scholar]
9. Manion L, Morrison K, Cohen L, editors . London: Routledge; 2011. Case studies, in Research Methos in Education; p. 289. [Google Scholar]
10. Ilfeld BM, Wright TW, Enneking FK, Vandenborne K. Total elbow arthroplasty as an outpatient procedure using a continuous infraclavicular nerve block at home: A prospective case report. Reg Anesth Pain Med. 2006; 31 :172–6. [PubMed] [Google Scholar]
11. Gopikrishna V. A report on case reports. J Conserv Dent. 2010; 13 :265–71. [PMC free article] [PubMed] [Google Scholar]
