Medical Case Reports
See also
Medical Case Reports
Reynaldo O. Joson, M.D.
Medical case reports are published scientific writings of unique, unusual, and rare medical diseases and events which are of informative value. The key words in this definition are the following: published, scientific, unique, unusual, rare, diseases, events, and informative.
A medical case report should be published in a reputable medical journal before it can be considered an official scientific writing.
A medical case report is a scientific writing as it involves some amount of research work consisting primarily of literature search and analysis and it is written in a scientific and systematic way.
What should be reported should be medical disease or events that are unique, unusual, or rare. The best case report is one that has not been previously reported in world literature.
However, with the literature filled with myriads of case reports, it is now extremely difficult to report what is considered as the first and the original case. Realizing this problem and considering the importance of case reports to medical practice, editors of medical journals allow reporting of rare cases, even those which had been previously published. Such cases, however, should be considered rare by international standards.
The medical case reports should be of informative value. They should not merely be everyone-should-remember cases. They should contain information that will enlarge, improve, or even change existing medical knowledge and practice.
A medical case report starts as an experience, rarely as a series of experience, which struck the physician's attention which he thinks is unique, unusual, or rare, that is worth publishing for its informative value. The next step is the literature search and analysis in which the physician decides whether the experience is really worth reporting and publishing.
If it is, the next step is the writing of the report. The last step is the publication of the report in a reputable medical journal.
Writing a medical case follows a standard format, which consists of the following:
Title
Author's name, institution, address
Introduction
Case presentation
History
Physical examination
Laboratory examination
Course in the hospital (in any)
Pathological findings (if any)
Discussion or comment
Summary or conclusion (if any)
References
Acknowledgment (if any)
Composing the various parts of a medical case report also follows some standard ways of scientific writing. Here are some guidelines and some do's and don'ts.
Title
The title should contain the fewest possible words that can adequately describe the content of the report. In other words, it should be brief and at the same time, descriptive and specific. The title should come in a label form and not in a sentence. Syntax is important in the making of a label-title.
No abbreviations should be used.
The title should be finalized after the report is completely written. It should not contain the phrase "review of literature" for all case reports presuppose that such a review is done.
Likewise, the title should not contain the phrase "report of a case or one case". A medical case report is usually a one-case report. Rarely, is it more than one case.
The following are examples of titles of medical case reports:
. Adenocarcinoma of the Appendix
. Intussusception of the Appendix
. Carcinoid Tumor of the Brain
. Blindness after Bilateral Neck Dissection
Introduction
In the introduction, the following should be included :
1. How the case came to the author's attention.
2. It's main features that make it rare, unusual or unique and worth reporting.
3. Briefly, what literature says about such a case.
4. The purpose of reporting.
Case Presentation
The case presentation should be a continuous flow of information of the patient's data. It is an account of the case containing pertinent accurate and clear data. Pictures and illustrations are included as necessary.
Discussion
The discussion is an expansion of the introduction. It is a detailed discussion that the case is unique or rare and that it is worth reporting. It also contains a review of literature; explanation for the medical events; implications of the case report in clinical practice; and possibilities for further study.
Summary or Conclusion
Conclusion, if any, is placed in the case report. If not, a summary suffices which contains a resume of the facts in the case report.
References
Only articles which contribute to the making of the paper are included. Format prescribed by medical journals to which the paper is submitted for publication should be followed.
Usually the listing is done in a chronological order as the reference is cited and not alphabetically. The following are examples of how references are usually listed:
Article
- Joson RO, Reyes JM, Cruz RP: Thyroid nodule aspiration: diagnostic usefulness and limitation. Phil J Surg Spec 5:46, 1989.
Book
- Major RJ: Physical Diagnosis. Philadelphia: WB Saunders, 1951.
Chapter in a Book
- Kunchert RO: Acute Appendicitis. In: Acute Abdomen. Kim D (ed). New York: Grune and Straton, 1985, p. 81.
More than 6 authors:
- Jones JO, Roe PJ, Santos JP, et al: Adenocarcinoma of the appendix. Phil J Surg Spec 5:50, 1975.
Senior, Junior and Roman Numerals
- Louis RV, Roe JO III, Cruz JT Jr: Blindness after thyroidectomy. JAMA 5:61, 1982.
Other Pointers and Advices
1. One should not claim the case being reported is the first or the only case in the world or in a country unless one is 100% sure.
2. One should not claim that there are no other reports of similar case in the country or in the world unless one is 100% sure.
3. The number of authors should be appropriately proportional to the making of a medical case report.
4. In case of multiple authorship, the senior author should be the one who did the actual writing of the report.
5. The primary tense used in writing a medical case report is the past tense.
6. The final paper, after several revisions, should be simple, orderly, clear, and accurate with correct grammar and spelling.
References
1. Agbayani BF: How to Write a Case Report: Some Common Pitfalls. In: Handbook of Medical Research. Philippines: DMCJ Printing Services, 1985, p. 157.
2. Day RA: How to Write and Publish a Scientific Paper. Philadelphia: ISI Press, 1979.
3. Huth JE: The Case Report. In: How To Write and Publish Papers in the Medical Sciences. Philadelphia: ISI Press, 1982, p. 58.