Writing A Case Report 5/20/21, 5:05 PM

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Wr i t i ng a C a s e Repor t
This page is intended for medical students, residents or others who do not have
much experience with case reports, but are planning on writing one.

What is a case report? A medical case report, also known as a case study, is a
detailed description of a clinical encounter with a patient. The most important
aspect of a case report, i.e. the reason you would go to the trouble of writing
one, is that the case is sufficiently unique, rare or interesting such that other
medical professionals will learn something from it.

Case reports are commonly of the following categories:

- Rare diseases
- Unusual presentation of disease

- Unexpected events

- Unusual combination of diseases or conditions

- Difficult or inconclusive diagnosis

- Treatment or management challenges

- Personal impact

- Observations that shed new light on a disease or condition

- Anatomical variations

It is important that you recognize what is unique or interesting about your case,
and this must be described clearly in the case report.

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Writing A Case Report 5/20/21, 5:05 PM

Case reports generally take the format of:

1. Background

2. Case presentation

3. Observations and investigation

4. Diagnosis

5. Treatment

6. Outcome

7. Discussion

Does a case report require IRB approval?

Case reports typically discuss a single patient. If this is true for your case report,
then it most likely does not require IRB approval because it not considered
research. If you have more than one patient, your study could qualify as a Case
Series, which would require IRB review. If you have questions, you chould check
your local IRB's guidelines on reviewing case reports.

Are there other rules for writing a case report?

First, you will be collecting protected health information, thus HIPAA applies to
case reports. Spectrum Health has created a very helpful guidance document
for case reports, which you can see here: Case Report Guidance - Spectrum
Health (/images/Documents/Case_Reports_Guidance.pdf)

While this guidance document was created by Spectrum Health, the rules and
regulations outlined could apply to any case report. This includes answering
questions like: Do I need written HIPAA authorization to publish a case report?
When do I need IRB review of a case report? What qualifies as a patient
identifier?
How do I get started?

1. We STRONGLY encourage you to consult the CARE Guidelines, which provide

guidance on writing case reports - https://www.care-statement.org/
(https://www.care-statement.org/)

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Writing A Case Report 5/20/21, 5:05 PM

Specifically, the checklist - https://www.care-statement.org/checklist

(https://www.care-statement.org/checklist) - which explains exactly the
information you should collect and include in your case report.

2. Identify a case. If you are a medical student, you may not yet have the clinical
expertise to determine if a specific case is worth writing up. If so, you must
seek the help of a clinician. It is common for students to ask attendings or
residents if they have any interesting cases that can be used for a case report.

3. Select a journal or two to which you think you will submit the case report.
Journals often have specific requirements for publishing case reports, which
could include a requirement for informed consent, a letter or statement from the
IRB and other things. Journals may also charge publication fees (see Is it free
to publish? below)

4. Obtain informed consent from the patient (see "Do I have to obtain informed
consent from the patient?" below). Journals may have their own informed
consent form that they would like you to use, so please look for this when
selecting a journal.
Once you've identified the case, selected an appropriate journal(s), and
considered informed consent, you can collect the required information to write
the case report.

How do I write a case report?

Once you identify a case and have learned what information to include in the
case report, try to find a previously published case report. Finding published
case reports in a similar field will provide examples to guide you through the
process of writing a case report.

One journal you can consult is BMJ Case Reports. As of 2020-2021, MSU has an
institutional fellowship with BMJ Case Reports which allows MSU faculty, staff
and students to publish in this journal for free. See this page for a link to the
journal and more information on publishing-
https://lib.msu.edu/medicalwriting_publishing/
(https://lib.msu.edu/medicalwriting_publishing/)
There are numerous other journals where you can find published case reports to
help guide you in your writing.

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Writing A Case Report 5/20/21, 5:05 PM

Do I have to obtain informed consent from the patient?

The CARE guidelines recommend obtaining informed consent from patients for
all case reports. Our recommendation is to obtain informed consent from the
patient. Although not technically required, especially if the case report does
not include any identifying information, some journals require informed consent
for all case reports. The CARE guidelines recommend obtaining informed
consent AND the patient's perspective on the treatment/outcome (if possible).
Please consider this as well.

If required, it is recommended you obtain informed consent before the case

report is written.

Seek feedback

Once you have written a draft of the case report, you should seek feedback on
your writing, from experts in the field if possible, or from those who have
written case reports before.

Selecting a journal
Aside from BMJ Case Reports mentioned above, there are many, many journals
out there who publish medical case reports. Ask your mentor if they have a
journal they would like to use. If you need to select on your own, here are some
strategies:

1. Do a PubMed search. https://pubmed.ncbi.nlm.nih.gov/

(https://pubmed.ncbi.nlm.nih.gov/)

a. Do a search for a topic, disease or other feature of your case report

b. When the results appear, on the left side of the page is a limiter for "article
type". Case reports are an article type you can limit your search results to.
If you don't see that option on the left, click "additional filters".

c. Review the case reports that come up, and see what journals they are
published in.

2. Use JANE - https://jane.biosemantics.org/ (https://jane.biosemantics.org/)

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Writing A Case Report 5/20/21, 5:05 PM

3. Check with specialty societies. Many specialty societies are affiliated with
one or more journal, which can be reviewed for ones that match your needs

4. Search through individual publisher journal lists. Elsevier publishes many

different medical research journals, and they have a journal finder, much like
JANE (https://journalfinder.elsevier.com/ (https://journalfinder.elsevier.com/)).
This is exclusive to Elsevier journals. There are many other publishers of medical
journals for review, including Springer, Dove Press, BMJ, BMC, Wiley, Sage,
Nature and many others.

Is it free to publish?

Be aware that it may not be free to publish your case report. Many journals
charge publication fees. Of note, many open access journals charge author fees
of thousands of dollars. Other journals have smaller page charges (i.e. $60 per
page), and still others will publish for free, with an "open access option". It is
best practice to check the journal's Info for Authors section or Author Center to
determine what the cost is to publish. CHM does NOT have funds to support
publication costs, so this is an important step if you do not want to pay out of
pocket for publishing.

References

Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. 2013. The CARE
guidelines: Consensus-based clinical case reporting guideline development.
Glob Adv Health Med. 2:38-43. doi: 10.7453/gahmj.2013.008
(https://dx.doi.org/10.7453%2Fgahmj.2013.008)

Riley DS, Barber MS, Kienle GS, AronsonJK, von Schoen-Angerer T, Tugwell P,
Kiene H, Helfand M, Altman DG, Sox H, Werthmann PG, Moher D, Rison RA,
Shamseer L, Koch CA, Sun GH, Hanaway P, Sudak NL, Kaszkin-Bettag M,
Carpenter JE, Gagnier JJ. 2017. CARE guidelines for case reports: explanation
and elaboration document (https://www.ncbi.nlm.nih.gov/pubmed/28529185). J
Clin Epidemiol. 89:218-234. doi: 10.1016/j.jclinepi.2017.04.026
Guidelines to writing a clinical case report. 2017. Heart Views. 18:104-
105. doi: 10.4103/1995-705X.217857 (https://dx.doi.org/10.4103%2F1995-
705X.217857)

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Writing A Case Report 5/20/21, 5:05 PM

Ortega-Loubon C, Culquichicon C, Correa R. The importance of writing and

publishing case reports during medical education. 2017. Cureus.
9:e1964. doi: 10.7759/cureus.1964 (https://dx.doi.org/10.7759%2Fcureus.1964)

Writing and publishing a useful and interesting case report. 2019. BMJ Case
Reports. https://casereports.bmj.com/pages/wp-
content/uploads/sites/69/2019/04/How-to-write-a-Case-Report-DIGITAL.pdf
(https://casereports.bmj.com/pages/wp-
content/uploads/sites/69/2019/04/How-to-write-a-Case-Report-DIGITAL.pdf)

Camm CF. Writing an excellent case report: EHJ Case Reports, Case of the Year
2019. 2020. European Heart Jounrnal. 41:1230-
1231. https://doi.org/10.1093/eurheartj/ehaa176
(https://doi.org/10.1093/eurheartj/ehaa176)

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