How to Write A Clinical Case Report

Professor Dr MD Abdul Wohab KhanMBBS, FCPS, MMEdProfessor and Head

Department of surgery And

A learner in Medical Educational Science

Workshop on

Writings that can be published in journals ?

• An original research paper – Describe the findings of an original research

• A short/brief communication – Abbreviated description of original research study

• A case report– Describe an unusual observation in usual cases or an

unusual case

Writings that can be published

• Letter to the editor– Some data not sufficient to publish a full length of paper

• Comment on recently published study – In the journal with a few line reporting your own finding

• Statement of a point of view (to the editor) – State your opinion or statement of facts on a topical

issue

• An editorial – Put forward a controversial or a new issue

• A review article – Meta-analysis – summarize the literature or series of studies – Systemic review - Literature review focused on a research

question to identify, appraise, select and synthesize high quality research evidence.

• An informal article– To wider reader to tell a recent event or a personal story of

scientific interest

The publishing process

Accepted/rejected

Journal editor

Referencing for scientific contents

Final article

Copy editor

In press

Proofs

Publication in journal

Libraries

Readers

Further references if needed(Scientific reference)

Statistical references

Two references(Peer review)

Author

Submit

Revisions

Accepted revision

Queries

Advise

• Please define/what you know about it – 2m

• Please come in front (any one interested) and share with others ---3m

What is a case?

• Case - a happening, an event or an occurrence

• Case reports are brief report – Describing and analyzing an isolated or a small number (1 to 3

or 5?) of clinical cases on diagnosis and/or management

• “Scientific observations……. carefully documented so that they may be a valuable education and research resource”

» ---- Sir William Osler

• ‘…Any patient that goes through the door of a hospital is a potential case report…’

Would you please mention the hierarchy of evidences in

research papers ?

Please discuss the place of case report (in groups) and Present it in front of the participants with logic

Hierarchy of evidences and its creation

RCT

Case control/cohort study

Case series

Case report

Case report

Case series

Meta-analysis

Systemic review

History

• Earliest in papyrus records (Egypt) @ 1600 B.C.. incurable tumors of the breast

• Melanoma by Hippocrates, 5th century B.C. – By Rufus of Ephesus, (Greek) - first century A.C.

• January 1832, Thomas Hodgkin - Hodgkin’s lymphoma.

• In 1941,– Stacy Guild (Johns Hopkins University)• Described a glomus body in the human temporal bone

– Harry Rosenwasser (New York) • operated a carotid body tumor from ear of a patient

– Dr. Rosenwasser communicated with Dr. Guild and both combinedly gave final case report • Established the clinical entity - glomus tumor

• AIDS - discovered on the basis of a case report – Extensively disseminated Kaposi’s sarcoma in the

American Journal of Dermato-pathology in 1981

In 1985

• AMA reprinted 51 papers that – Had significantly changed the medical

science and practice

– Published within last 150 years

– 5 of these papers were case reports

So case report is ----not a “second class” publication

It is the foundation of all research

Types

• Diagnostic/assessment reports– Describe and discusses the rare, confusing, or difficult

cases

• Treatment or management reports – Full management & assessment with in depth

understanding

• Educational reports (CME reports)– Brief review of the literature to provide current practice

strategies – Old cases with new & innovative perspective view

• An unusual or unknown disorder/clinical presentation

• Pointing to unusual etiology for a case

• Present a challenging differential diagnosis

• Describing mistakes in health care, their causes and consequences

• Describing an unusual setting for care

• Presenting information with ethical question

• Illustrating or supporting a hypothesis

• Pointing in favor or against a hypothesis

Publishable case reports

• To stimulate further research

• To offer new insight into the disease

• To describe improved or unique technical procedures

• To describe the historical development of a field or movement

• To report unusual drug-drug, drug-food, or drug-nutrient interactions

• To describe rare or novel adverse reactions to care

Study Design of Case Reports

• It is a descriptive study

• In depth naturalistic and qualitative

• Usually it is retrospective as it is not a pre-planned research

• Can experimental and prospective design “A case study” – Ligating PDA in 1939 (Anwar ul haque et al 2009) – Endoscopic Para-thyroidectomy in BSMMU in 2007(Aziz and Khan

2010)

In which section will you publish the case report?

Sections in peer reviewed journal

– ‘Case report’ section

– ‘Clinical case conference’

– ‘Technical report’

– ‘Letter to the editor’ and

– ‘Evidence based case report’

Writing a case report

Planning • Careful planning is essential for

– All good research project– Good scientific writing

So Take time to plan – Sections – Subsections – Paragraphs – Sentences

The three question

• What I am going to report?

• How should I report it ?

• In which Journal ?

Case report format

Please discus among the group 3m

Present and discuss (one from each group) 5m

Reporting format of scientific article

IMRAD

Introduction, objectives, literature review

Methodology

Result

And

Discussion

• Introduction and objective with a literature review

• Description of the case

• Discussion with a detailed explanation of the literature review

• Summary of the case, and a conclusion

Submission for publication

• Read the information for the Authors for The intended Journal• Write in separate pages

– Title

– Abstract and key words

– Introduction and objectives with (literature review)

– Description of the case report

– Discussion with Case summary

• Conclusion

• Supplementary materials – Tables – Figures – Graphs – Illustrations

• 1500 to 2500 words

• 20-30 references

Tea break

10 m

Title Page

• Provide the title

• Full name(s) of the author(s), – Institutional addresses

and– Email addresses

• Indicate the corresponding author

The title should be

• Descriptive • Accurate • Succinct

Practices on title

• “A 4-month-old boy presenting with anaphylaxis to a banana: a case report”

• “Spontaneous ejaculation’ A rare symptom in post traumatic stress disorder”

• “Neurofibromatosis induced hip arthritis. An unusual presentation”

Abstract

• Write the abstract lastly

• Polish it till it s just right

• Word limit’ Structured (with headings) or unstructured (single paragraph)

• No abbreviation or references

Abstract

• Please state briefly the conclusion and

• State how it will influences in practice or advancement in knowledge

• Keywords– Words representing the main content (Three to

ten)

Apply reviewers check list

Introduction and objective

Case report

Discussion

Conclusion

Introduction• Describe the subject (Concise and salient )to

clarify - background information/evidences

• State and the strategy and extant of literature search– Date, database, language, search terms/key

words.– Easily reproducible – Must cover the relevant database

• Narrate the purpose and merit with review of the reports

• Justify the case report (focused comprehensive literature review)– Begin what is known – Move to what is new – Highlight the implication

• Introduce the case to the reader

• Select references carefully– Limit the length– Do not overinflate than discussion

Apply reviewer check list

Subject matter describedPurpose statedBackground information providedPertinent definitions given Merit of the case report justified; using

literature reviewCase introduced to the readerIntroduction is brief (< 3 Paragraph)

Case Presentation

Follow the basic clinical rule

• Think what question might be asked by your colleagues– Ensure the answer within the report

• Add photographs, line diagrams, graphs, measurements and summary tables – To enhance readers understanding– Not to decorate

• It is wise to obtain written consent

Apply reviewers check listDescribe the case in a narrative form

Provide patient demographics (age, sex, height, weight, race, occupation) but avoid identification

Avoid patient identifiers (date of birth, initials)

Describe the patient’s complaint.

List the patient’s present illness

• List the patient’s family, social, medication, allergic, drug reaction, dietary history

• Provide pertinent findings on physical examination

• Provide pertinent laboratory values that support the case– Renal and hepatic organ function data

Reviewers check list

• List the completed diagnostic procedures that are pertinent and support the case

• Paraphrase the salient diagnostic procedures

• Provide photographs of – histopathology, X-rays, ECG, skin manifestations,

or anatomy as they relate to the case

• Obtain permission from the patient to use the patient’s photographs or follow institutional guidelines

• Provide the patient’s events in chronological order to– Ensure a temporal relationship– Ensure a causal relationship– Ensure that the patient case presentation provides

enough detail for the reader to establish the case’s validity.

Discussion

• Compare and contrast with literature review to - – Evaluate the case for accuracy, validity and uniqueness

• Explain and Justify - – differences and similarities

• List - – the limitations and relevancies

• Summarize the essential features – To justify uniqueness of the case, conclusion and recommendation

Compare and contrast with critically evaluated literature review

Explain or justify with valid literature

Franck to list the limitations and describe their relevance

Confirm the accuracy of the descriptive patient case report

Summarize the salient features of the case report

Justify the uniqueness of the case

Draw recommendations and conclusions

Logical and succinct

Well referenced

Conclusion and recommendationThis should be brief and not exceeding one paragraph

Justified and evidence based

Recommend and list opportunities for future research

Give guideline for utilizing the information in practice

Practical sequences

• Write the case description in detail first

• Discussion next

• Then conclusion

• Now finalize the ‘Title’

• Introduction

• Abstract – should be the last thing to write

Don’ts in A Case report

• Does not need to be headed as “Introduction”

• Should not contain confusing information

• No headings in history

• No verbatim description of physical and laboratory findings

• Don’t provide patient identity in any form

• Don't duplicate information in in other part of the text

• Don’t make firm judgment

• No speculative or sweeping recommendation

Case report and law/ethics

• Research is a systematic investigation to develop or contribute to generalizable knowledge

• A case report is anecdotal medical/ educational activity that does not meet the definition of research

• So case or case series presenting at a teaching conference does not require IRB review

• Authorship – One dealing with and be responsible for

everything

– One having significant input

Assignment

Please collect a case and

Write a report on it and

Submit the report to the organizer for review

Within two weeks

Thank you