Case Report: A Beginner’s Guide with Examples

A case report is a descriptive study that documents an unusual clinical phenomenon in a single patient. It describes in details the patient’s history, signs, symptoms, test results, diagnosis, prognosis and treatment. It also contains a short literature review, discusses the importance of the case and how it improves the existing knowledge on the subject.

A similar design involving a group of patients (with the similar problem) is referred to as case series.

Advantages of case reports

Case reports offer, in general a fast, easy and cheap way to report an unusual observation or a rare event in a clinical setting, as these have very small probability of being detected in an experimental study because of limitations on the number of patients that can be included.

These events deserve to be reported since they might provide insights on some exceptions to general rules and theories in the field.

Case reports are great to get first impressions that can generate new hypotheses (e.g. detecting a potential side effect of a drug) or challenge existing ones (e.g. shedding the light on the possibility of a different biological mechanism of a disease).

In many of these cases, additional investigation is needed such as designing large observational studies or randomized experiments or even going back and mining data from previous research looking for evidence for theses hypotheses.

Limitations of case reports

Observing a relationship between an exposure and a disease in a case report does not mean that it is causal in nature.

This is because of:

  • The absence of a control group that provides a benchmark or a point of reference against which we compare our results. A control group is important to eliminate the role of external factors which can interfere with the relationship between exposure and disease
  • Unmeasured Confounding caused by variables that influence both the exposure and the disease

A case report can have a powerful emotional effect (see examples of case reports below). This can lead to overrate the importance of the evidence provided by such case. In his book Against Empathy: The Case for Rational Compassion , Paul Bloom explains how a powerful story affects our emotions, can distort our judgement and even lead us to make bad moral choices.

When a case report describes a rare event it is important to remember that what we’re reading about is exceptional and most importantly resist generalizations especially because a case report is, by definition, a study where the sample is only 1 patient.

Selection bias is another issue as the cases in case reports are not chosen at random, therefore some members of the population may have a higher probability of being included in the study than others.

So, results from a case report cannot be representative of the entire population.

Because of these limitations, case reports have the lowest level of evidence compared to other study designs as represented in the evidence pyramid below:

Pyramid representing the levels of evidence for each study design

Real-world examples of case reports

Example 1: normal plasma cholesterol in an 88-year-old man who eats 25 eggs a day.

This is the case of an old man with Alzheimer’s disease who has been eating 20-30 eggs every day for almost 15 years. [ Source ]

The man had an LDL-cholesterol level of only 142 mg/dL (3.68 mmol/L) and no significant clinical atherosclerosis (deposition of cholesterol in arterial walls)!

His body adapted by reducing the intestinal absorption of cholesterol, lowering the rate of its synthesis and increasing the rate of its conversion into bile acid.

This is indeed an unusual case of biological adaptation to a major change in dietary intake.

Example 2: Recovery from the passage of an iron bar through the head

This is an interesting case of a construction foreman named Phineas Gage. [ Source ]

In 1848, due to an explosion at work, an iron bar passed through his head destroying a large portion of his brain’s frontal lobe. He survived the event and the injury only affected 1 thing: His personality!

After the accident, Gage became profane, rough and disrespectful to the extent that he was no longer tolerable to people around him. So he lost his job and his family.

His case inspired further research that focused on the relationship between specific parts of the brain and personality.

  • Sayre JW, Toklu HZ, Ye F, Mazza J, Yale S.  Case Reports, Case Series – From Clinical Practice to Evidence-Based Medicine in Graduate Medical Education .  Cureus . 2017;9(8):e1546. Published 2017 Aug 7. doi:10.7759/cureus.1546.
  • Nissen T, Wynn R.  The clinical case report: a review of its merits and limitations .  BMC Res Notes . 2014;7:264. Published 2014 Apr 23. doi:10.1186/1756-0500-7-264.

Further reading

  • Case Report vs Cross-Sectional Study
  • Cohort vs Cross-Sectional Study
  • How to Identify Different Types of Cohort Studies?
  • Matched Pairs Design
  • Randomized Block Design

CHM Office of Reseach

Writing a Case Report

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.

Case reports generally take the format of :

1. Background

2. Case presentation

3. Observations and investigation

4. Diagnosis

5. Treatment

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

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/

Specifically, the 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 .  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/

There are numerous other journals where you can find published case reports to help guide you in your writing. 

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 before publishing.  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.

An example of a case report consent form can be found on the BMJ Case Reports website, which you can access via the MSU library page -  https://casereports.bmj.com/ .  Go to "Instructions for Authors" and then "Patient Consent" to find the consent form they use.  You can create a similar form to obtain consent from your patient.  If you have identified a journal already, please consult their requirements and determine if they have a specific consent form they would like you to use.

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/

   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 to which you can limit your search results.  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/

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/ ).  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.  MSU-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

*A more thorough discussion on finding a journal, publication costs, predatory journals and other publication-related issues can be found here:   https://research.chm.msu.edu/students-residents/finding-a-journal

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

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 . 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

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

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

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  

*content developed by Mark Trottier, PhD

Study Design 101

  • Helpful formulas
  • Finding specific study types

Case Report

  • Meta- Analysis
  • Systematic Review
  • Practice Guideline
  • Randomized Controlled Trial
  • Cohort Study
  • Case Control Study
  • Case Reports

An article that describes and interprets an individual case, often written in the form of a detailed story. Case reports often describe:

  • Unique cases that cannot be explained by known diseases or syndromes
  • Cases that show an important variation of a disease or condition
  • Cases that show unexpected events that may yield new or useful information
  • Cases in which one patient has two or more unexpected diseases or disorders

Case reports are considered the lowest level of evidence, but they are also the first line of evidence, because they are where new issues and ideas emerge. This is why they form the base of our pyramid. A good case report will be clear about the importance of the observation being reported.

If multiple case reports show something similar, the next step might be a case-control study to determine if there is a relationship between the relevant variables.

  • Can help in the identification of new trends or diseases
  • Can help detect new drug side effects and potential uses (adverse or beneficial)
  • Educational – a way of sharing lessons learned
  • Identifies rare manifestations of a disease

Disadvantages

  • Cases may not be generalizable
  • Not based on systematic studies
  • Causes or associations may have other explanations
  • Can be seen as emphasizing the bizarre or focusing on misleading elements

Design pitfalls to look out for

The patient should be described in detail, allowing others to identify patients with similar characteristics.

Does the case report provide information about the patient's age, sex, ethnicity, race, employment status, social situation, medical history, diagnosis, prognosis, previous treatments, past and current diagnostic test results, medications, psychological tests, clinical and functional assessments, and current intervention?

Case reports should include carefully recorded, unbiased observations.

Does the case report include measurements and/or recorded observations of the case? Does it show a bias?

Case reports should explore and infer, not confirm, deduce, or prove. They cannot demonstrate causality or argue for the adoption of a new treatment approach.

Does the case report present a hypothesis that can be confirmed by another type of study?

Fictitious Example

A physician treated a young and otherwise healthy patient who came to her office reporting numbness all over her body. The physician could not determine any reason for this numbness and had never seen anything like it. After taking an extensive history the physician discovered that the patient had recently been to the beach for a vacation and had used a very new type of spray sunscreen. The patient had stored the sunscreen in her cooler at the beach because she liked the feel of the cool spray in the hot sun. The physician suspected that the spray sunscreen had undergone a chemical reaction from the coldness which caused the numbness. She also suspected that because this is a new type of sunscreen other physicians may soon be seeing patients with this numbness.

The physician wrote up a case report describing how the numbness presented, how and why she concluded it was the spray sunscreen, and how she treated the patient. Later, when other doctors began seeing patients with this numbness, they found this case report helpful as a starting point in treating their patients.

Real-life Examples

Hymes KB. Cheung T. Greene JB. Prose NS. Marcus A. Ballard H. William DC. Laubenstein LJ. (1981). Kaposi's sarcoma in homosexual men-a report of eight cases. Lancet. 2(8247), 598-600.

This case report was published by eight physicians in New York city who had unexpectedly seen eight male patients with Kaposi’s sarcoma (KS). Prior to this, KS was very rare in the U.S. and occurred primarily in the lower extremities of older patients. These cases were decades younger, had generalized KS, and a much lower rate of survival. This was before the discovery of HIV or the use of the term AIDS and this case report was one of the first published items about AIDS patients.

Wu, E. B., & Sung, J. J. Y. (2003). Haemorrhagic-fever-like changes and normal chest radiograph in a doctor with SARS. Lancet, 361(9368), 1520-1521.

This case report is written by the patient, a physician who contracted SARS, and his colleague who treated him, during the 2003 outbreak of SARS in Hong Kong. They describe how the disease progressed in Dr. Wu and based on Dr. Wu’s case, advised that a chest CT showed hidden pneumonic changes and facilitate a rapid diagnosis.

Related Terms

Case Series

A report about a small group of similar cases.

Preplanned Case-Observation

A case in which symptoms are elicited to study disease mechanisms. (Ex. Having a patient sleep in a lab to do brain imaging for a sleep disorder).

Now test yourself!

1. Case studies are not considered evidence-based even though the authors have studied the case in great depth.

a) True b) False

2. When are Case reports most useful?

a) When you encounter common cases and need more information b) When new symptoms or outcomes are unidentified c) When developing practice guidelines d) When the population being studied is very large

← Previous Next →

© 2011-2019, The Himmelfarb Health Sciences Library Questions? Ask us .

Creative Commons License

  • Himmelfarb Intranet
  • Privacy Notice
  • Terms of Use
  • GW is committed to digital accessibility. If you experience a barrier that affects your ability to access content on this page, let us know via the Accessibility Feedback Form .

Weill Cornell Medicine Samuel J. Wood Library

Case Reports: How to Write a Case Report

  • How to Write a Case Report
  • Case Report Resources
  • YouTube Resources

Consensus-Based Clinical Case Reporting Guidelines

a case report example

Gagnier JJ, Riley D, Altman DG, Moher D, Sox H, Kienle GS, for the CARE group: The CARE guidelines: Consensus-based clinical case reporting guideline development. Dtsch Arztebl  Int 2013; 110(37): 603-8.

Select Journals Accepting Case Reports

Case report templates.

The CAse REporting (CARE)  team created templates in nine languages to assist clinicians, researchers, and educators with the ultimate goal of improving the completeness, transparency, and usefulness of case reports.  

English , Spanish , German , Chinese , Dutch , French , Japanese , Korean , Portuguese

  • Case Report Journals

A list of case report journals can be found in the pdf below. It provides information on the year launched, open-access status, reported questionable publishing practices, and whether the journal is indexed in Medline. The majority of these journals are open-access and will require a submission fee.

BMJ Case Reports

  • BMJ Consent Form

The Library has an institutional fellowship with  BMJ Case Reports  which allows faculty, staff, and students at Weill Cornell Medicine to submit case reports without paying an individual fellowship fee. Use our  fellowship code  when you are ready to publish. 

Please note: BMJ Case Reports, like most journals, requires a signed consent form in order for a case report to be considered for publication. 

  • << Previous: Home
  • Next: Case Report Resources >>
  • Last Updated: Aug 15, 2022 12:15 PM
  • URL: https://med.cornell.libguides.com/casereports

a case report example

How to Write and Publish a Case Report

Choosing a case to report, components of a case report, author information, introduction, case description/summary, notes on patient consent.

  • Finding Journals to Publish In
  • Writing Resources
  • Related Library Resources
  • Contact a Librarian
  • Back to Library Home Page This link opens in a new window

Necessary Criteria:

  • Your case report should not be previously represented in medical literature- that means you need to do a literature search
  • Complete- you should have enough information in the file to present the case

Characteristics that make cases more likely to be published:

  • Cases that contribute to a change in the course of medical science
  • Cases that illustrate a new principle or support or refute a current theory and thus may stimulate research
  • Cases that present a therapeutic or diagnostic observation that elucidates a previously misunderstood clinical condition or response
  • Cases that demonstrate an adverse response to drug therapies or presumed cause-and-effect presentations that have not been detected or reported
  • An unusual combination of conditions, cascading events, or presenting complaints that confused the decision-making process or created treatment dilemmas
  • A new observation of the impact of one disease process or condition on another, or of a treatment regime for one condition that results in an unexpected outcome of a different condition
  • Case reports that describe the personal influence a particular event had on a patient, the physician, or both

Packer, Clifford D., et al.  Writing Case Reports : A Practical Guide from Conception Through Publication , Springer International Publishing AG, 2016.  ProQuest Ebook Central , https://ebookcentral.proquest.com/lib/templeuniv-ebooks/detail.action?docID=4732576.

Different journals have slightly different formats for case reports. But, in general, all case reports include the following components: an abstract, an introduction, a case, and a discussion. 

Source: Guidelines To Writing A Clinical Case Report. Heart Views. 2017 Jul-Sep;18(3):104-105. doi: 10.4103/1995-705X.217857. PMID: 29184619; PMCID: PMC5686928.

  • You should aim for completeness. Use full names and formal credentials; department and institution worked. The author information usually does NOT count against the total word count but be sure you check the instructions.
  • There may be a limit on how many authors can be on the submission.
  • The first author is the one who conceived the report and did most of the work.
  • Full disclosure on sponsors.

Your best strategy in writing a title: Write the abstract first.  Then pull out 6-10 key words or key phrases found in the abstract, and string them together into various titles. Brainstorm lots of keywords to help find the best mix. Use action words that concisely portrays the message of your case report. Some journals require the words "case report" in the title, check the guidelines. 

The title should be:

  • Ideally 10-12 words long. Look for a limit on how many characters the title can be on the journal website once you've figured out where to submit. Look for further rules about the title: Upper- and lowercase letters only.
  • Make the title a description of what was investigated (not the results or conclusion); convey as much as possible about the context and aims of the case. 
  • Avoid low-impact phrases like ‘effect of... ‘ or ‘influence of…’; Do not include jargon or unfamiliar acronyms.

The abstract should summarize the case, the problem it addresses, and the message it conveys. Abstracts of case reports are usually very short, preferably not more than 150 words.

The introduction gives a brief overview of the problem that the case addresses, citing relevant literature where necessary. The introduction generally ends with a single sentence describing the patient and the basic condition that he or she is suffering from.

This section provides the details of 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

The author should ensure that all the relevant details are included and unnecessary ones excluded.

This is the most important part of the case report; the part that will convince the journal that the case is publication worthy. This section should start by expanding on what has been said in the introduction, focusing on why the case is noteworthy and the problem that it addresses.

This is followed by a summary of the existing literature on the topic. (If the journal specifies a separate section on literature review, it should be added before the Discussion). This part describes the existing theories and research findings on the key issue in the patient's condition. The review should narrow down to the source of confusion or the main challenge in the case.

Finally, the case report should be connected to the existing literature, mentioning the message that the case conveys. The author should explain whether this corroborates with or detracts from current beliefs about the problem and how this evidence can add value to future clinical practice.

A case report ends with a conclusion or with summary points, depending on the journal's specified format. This section should briefly give readers the key points covered in the case report. Here, the author can give suggestions and recommendations to clinicians, teachers, or researchers. Some journals do not want a separate section for the conclusion: it can then be the concluding paragraph of the Discussion section.

Informed consent in an ethical requirement for most studies involving humans, so before you start writing your case report, take a written consent from the patient as most journals require that you provide it at the time of manuscript submission. In case the patient is a minor, parental consent is required. For adults who are unable to consent to investigation or treatment, consent of closest family members is required.

Patient anonymity is also an important requirement. Remember not to disclose any information that might reveal the identity of the patient. You need to be particularly careful with pictures, and ensure that pictures of the affected area do not reveal the identity of the patient.

The references section should include citations to any resources you referenced in your case report.

  • << Previous: Home
  • Next: Finding Journals to Publish In >>
  • Last Updated: Feb 26, 2024 10:39 AM
  • URL: https://guides.temple.edu/c.php?g=1336360

Temple University

University libraries.

See all library locations

  • Library Directory
  • Locations and Directions
  • Frequently Called Numbers

Twitter Icon

Need help? Email us at [email protected]

  • Open access
  • Published: 06 April 2016

How to review a case report

  • Rakesh Garg 1 ,
  • Shaheen E. Lakhan 2 &
  • Ananda K. Dhanasekaran 3  

Journal of Medical Case Reports volume  10 , Article number:  88 ( 2016 ) Cite this article

68k Accesses

19 Citations

3 Altmetric

Metrics details

Peer Review reports

Introduction

Sharing individual patient experiences with clinical colleagues is an essential component of learning from each other. This sharing of information may be made global by reporting in a scientific journal. In medicine, patient management decisions are generally based on the evidence available for use of a particular investigation or technology [ 1 ]. The hierarchical rank of the evidence signifies the probability of bias. The higher up the hierarchy, the better its reliability and thus its clinical acceptance (Table  1 ). Though case reports remain lowest in the hierarchy of evidence, with meta-analysis representing the highest level, they nevertheless constitute important information with regard to rare events and may be considered as anecdotal evidence [ 2 ] (Table  1 ). Case reports may stimulate the generation of new hypotheses, and thus may support the emergence of new research.

The definition of a case report or a case series is not well defined in the literature and has been defined variously by different journals and authors. However, the basic definition of a case report is the detailed report of an individual including aspects like exposure, symptoms, signs, intervention, and outcome. It has been suggested that a report with more than four cases be called a case series and those with fewer than four a case report [ 3 ]. A case series is descriptive in design. Other authors describe “a collection of patients” as a case series and “a few patients” as a case report [ 4 ]. We suggest that should more than one case be reported, it may be defined as a case series—a concept proposed by other authors [ 5 ].

The importance of case reports

A case report may describe an unusual etiology, an unusual or unknown disorder, a challenging differential diagnosis, an unusual setting for care, information that can not be reproduced due to ethical reasons, unusual or puzzling clinical features, improved or unique technical procedures, unusual interactions, rare or novel adverse reactions to care, or new insight into the pathogenesis of disease [ 6 , 7 ]. In recent years, the publication of case reports has been given low priority by many high impact factor journals. However, the need for reporting such events remains. There are some journals dedicated purely to case reports, such as the Journal of Medical Case Reports , emphasizing their importance in modern literature. In the past, isolated case reports have led to significant advancements in patient care. For example, case reports concerning pulmonary hypertension and anorexic agents led to further trials and the identification of the mechanism and risk factors associated with these agents [ 2 , 8 ].

Reporting and publishing requirements

The reporting of cases varies for different journals. The authors need to follow the instructions for the intended publication. Owing to significant variability, it would be difficult to have uniform publication guidelines for case reports. A checklist called the CARE guidelines is useful for authors writing case reports [ 9 , 10 ]. However, it would be universally prudent to include a title, keywords, abstract, introduction, patient information, clinical findings, timeline, diagnostic assessment, therapeutic interventions, follow-up and outcomes, discussion, patient perspective, and informed consent.

Peer review process

The peer review process is an essential part of ethical and scientific writing. Peer review ultimately helps improve articles by providing valuable feedback to the author and helps editors make a decision regarding publication. The peer reviewer should provide unbiased, constructive feedback regarding the manuscript. They may also highlight the strengths and weaknesses of the report. When reviewing an article, it is prudent to read the entire manuscript first to understand the overall content and message. The reviewer than may read section-wise and provide comments to the authors and editorial team accordingly. The reviewer needs to consider the following important points when reviewing a case for possible publication [ 8 , 9 ] (summarized in Table  2 ).

Novelty remains the foremost important aspect of a case. The case report should introduce novel aspects of patient evaluation, investigation, treatment, or any other aspect related to patient care. The relevant information becomes a hypothesis generator for further study. The novelty may at times be balanced with some important information like severe adverse effects, even if they have been reported earlier. Reporting adverse events remains important so that information on cumulative adverse effects can be gathered globally, which helps in preparing a policy or guideline or a warning note for its use in patients. The data related to adverse effects include not only the impact but also the number of patients affected. This becomes more important for serious adverse effects. In the absence of an international registry for adverse effects, published case reports are important pieces of information. Owing to ethical concerns, formal evaluation may not be feasible in the format of prospective study.

Essential description

The case needs to have all essential details to allow a useful conclusion to emerge. For example, if a case is being reported for hemodynamic variability due to a drug, then the drug dose and timing along with timed vital signs need to be described.

Authenticity and genuineness

Honesty remains the most important basic principle of all publications. This remains a primary responsibility of the authors. However, if there is any doubt, reviewers may seek clarification. This doubt may result from some discordance in the case description. At times, a lack of correlation between the figures and description may act as “red flags.” For instance, authors may discuss a technique for dealing with a difficult airway, but the figure is of a normal-appearing airway. Another example would be where the data and figure do not correlate in a hemodynamic response related to a drug or a technique, with the graphical picture or screenshot of hemodynamics acting as an alert sign. Such cause for concern may be communicated in confidence to the editor.

Ethical or competing interests

Ethical issues need to be cautiously interpreted and communicated. The unethical use of a drug or device is not desirable and often unworthy of publication. This may relate to the route or dose of the drug administered. The off-label use of drugs where known side effects are greater than potential benefit needs to be discouraged and remains an example of unethical use. This use may be related to the drug dose, particularly when the drug dose exceeds the routine recommended dose, or to the route of administration. As an example, the maximal dose of acetaminophen (paracetamol) is 4g/day, and if an author reports exceeding this dose, it should be noted why a greater than recommended dose was used. Ultimately, the use of a drug or its route of administration needs to be justified in the manuscript. The reviewers need to serve as content experts regarding the drugs and other technologies used in the case. A literature search by the reviewer provides the data to comment on this aspect.

Competing interests (or conflicts of interest) are concerns that interfere or potentially interfere with presentation, review, or publication. They must be declared by the authors. Conflicts can relate to patient-related professional attributes (like the use of a particular procedure, drug, or instrument) being affected by some secondary gains (financial, non-financial, professional, personal). Financial conflict may be related to ownership, paid consultancy, patents, grants, honoraria, and gifts. Non-financial conflicts may be related to memberships, relationships, appearance as an expert witness, or personal convictions. At times, the conflict may be related to the author’s relationship with an organization or another person. A conflict may influence the interpretation of the outcome in an inappropriate and unscientific manner. Although conflicts may not be totally abolished, they must be disclosed when they reasonably exist. This disclosure should include information such as funding sources, present membership, and patents pending. Reviewers should cautiously interpret any potential bias regarding the outcome of the case based on the reported conflicts. This is essential for transparent reporting of research. At times, competing interests may be discovered by a reviewer and should be included in comments to the editorial team. Such conflicts may again be ascertained when the reviewer reviews the literature during the peer review process. The reviewer should also disclose their own conflicts related to the manuscript review when sending their report to the editorial team.

Impact on clinical practice

This is an important aspect for the final decision of whether to publish a case report. The main thrust or carry-home message needs to be emphasized clearly. It needs to be elaborated upon in concluding remarks.

Patient anonymity, consent, and ethical approval

When reviewing the manuscript of a case report, reviewers should ensure that the patient’s anonymity and confidentiality is protected. The reviewers should check that patient identifiers have been removed or masked from all aspects of the manuscript, whether in writing or within photograph. Identifiers can include things like the name of the patient, geographical location, date of birth, phone numbers, email of the patient, medical record numbers, or biometric identifiers. Utmost care needs to be taken to provide full anonymity for the patient.

Consent is required to participate in research, receive a certain treatment, and publish identifiable details. These consents are for different purposes and need to be explained separately to the patient. A patient’s consent to participate in the research or for use of the drug may not extend to consent for publication. All these aspects of consent must be explained to the patient, written explicitly in the patient’s own language, understood by the patient, and signed by the patient. For the purpose of the case, the patient must understand and consent for any new technique or drug (its dose, route, and timing) being used. In the case of a drug being used for a non-standard indication or route, consent for use must also be described. Patient consent is essential for the publication of a case if patient body parts are displayed in the article. This also includes any identifiers that can reveal the identity of the patient, such as the patient’s hospital identification number, address, and any other unique identifier. In situations where revealing the patient’s identity cannot be fully avoided, for example if the report requires an image of an identifiable body part like the face, then this should be explained to the patient, the image shown to them, and consent taken. Should the patient die, then consent must be obtained from next of kin or legal representative.

With case series, securing individual patient consent is advised and preferable. The authors may also need institutional review board (IRB) approval to publish a case series. IRBs can waive the need for consent if a study is conducted retrospectively and data are collected from patient notes for the purpose of research, usually in an anonymized way. However, wherever possible, individual patient consent is preferable, even for a retrospective study. Consent is mandatory for any prospective data collection for the purpose of publication as a case series. Consent and/or IRB approval must be disclosed in the case report and reasons for not obtaining individual consent may be described, if applicable.

There may be situations in which publishing patient details without their consent is justified, but this is a decision that should be made by the journal editor, who may decide to discuss the case with the Committee on Publication Ethics. Reviewers need to emphasize the issue to the editor when submitting their comments.

Manuscript writing

The CARE guidelines provide a framework that supports transparency and accuracy in the publication of case reports and the reporting of information from patient encounters. The acronym CARE was created from CA (the first two letters in “case”) and RE (the first two letters in “reports”). The initial CARE tools are the CARE checklist and the Case Report Writing Templates. These tools support the writing of case reports and provide data that inform clinical practice guidelines and provide early signals of effectiveness, harms, and cost [ 10 ].

The presentation of the case and its interpretation should be comprehensive and related. The various components of the manuscript should have sufficient information for understanding the key message of the case. The reviewer needs to comment on the relevant components of the manuscript. The reviewer should ascertain that the title of the case manuscript is relevant and includes keywords related to the case. The title should be short, descriptive, and interesting. The abstract should be brief, without any abbreviations, and include keywords. It is preferable to use Medical Subject Headings (MeSH) keywords. Reviewers must ensure that the introduction emphasizes the context of the case and describes the relevance and its importance in a concise and comprehensive manner. The case description should be complete and should follow basic rules of medical communication. The details regarding patient history, physical examination, investigations, differential diagnosis, management, and outcome should be described in chronological order. If repeated observations are present, then they may be tabulated. The use of graphs and figures helps the readers to better understand the case. Interpretation or inferences based on the outcomes should be avoided in this section and should be considered a part of the discussion. The discussion should highlight important aspects of the case, with its interpretation within the context of the available literature. References should be formatted as per the journal style. They should be complete and preferably of recent publications.

Reviewer responsibility

The reviewer’s remarks are essential not only for the editorial team but also for authors. A good peer review requires honesty, sincerity, and punctuality. Even if a manuscript is rejected, the authors should receive learning points from peer review commentary. The best way to review a manuscript is to read the manuscript in full for a gross overview and develop general comments. Thereafter, the reviewer should address each section of the manuscript separately and precisely. This may be done after a literature search if the reviewer needs to substantiate his/her commentary.

Constructive criticism

The reviewer’s remarks should be constructive to help the authors improve the manuscript for further consideration. If the manuscript is rejected, the authors should have a clear indication for the rejection. The remarks may be grouped as major and minor comments. Major comments likely suggest changes to the whole presentation, changing the primary aim of the case report, or adding images. Minor comments may include grammatical errors or getting references for a statement. The editorial team must be able to justify their decision on whether or not to accept an article for publication, often by citing peer review feedback. It is also good style to tabulate a list of the strengths and weaknesses of the manuscript.

Fixed time for review

Reviewer remarks should be submitted within a specified timeframe. If any delay is expected, it should be communicated to the editorial team. Reviewers should not rush to submit feedback without sufficient time to adequately review the paper and perform any necessary literature searches. Should a reviewer be unable to submit the review within the specified timeframe, they should reply to the review invitation to decline at their earliest convenience. If, after accepting a review invitation, the reviewer realizes they do not have time to perform the review, this must be communicated to the editorial team.

Conflict of interest

The reviewer’s conflicts of interest should be included along with the review. The conflicts may be related to the contents of the case, drugs, or devices pertaining to the case; the author(s); or the affiliated institution(s) of the author(s).

Lack of expertise

The reviewer may decline to review the manuscript if they think the topic is out of their area of expertise. If, after accepting an invitation to review, the reviewer realizes they are unable to review the manuscript owing to a lack of expertise in that particular field, they should disclose the fact to the editorial team.

Confidentiality

The reviewer should keep the manuscript confidential and should not use the contents of the unpublished manuscript in any form. Discussing the manuscript among colleagues or any scientific forum or meetings is inappropriate.

Review of revised manuscript

At times, a manuscript is sent for re-review to the reviewer. The reviewer should read the revised manuscript, the author’s response to the previous round of peer review, and the editorial comments. Sometimes, the authors may disagree with the reviewer’s remarks. This issue needs to be elaborated on and communicated with the editor. The reviewer should support their views with appropriate literature references. If the authors justify their reason for disagreeing with the viewer, then their argument should be considered evidence-based. However, if the reviewer still requests the revision, this may be politely communicated to the author and editor with justification for the same. In response to reviewers remarks, authors may not agree fully and provide certain suggestion in the form of clarification related to reviewers remarks. The reviewers should take these clarifications judiciously and comment accordingly with the intent of improving the manuscript further.

Peer reviewers have a significant role in the dissemination of scientific literature. They act as gatekeepers for science before it is released to society. Their sincerity and dedication is paramount to the success of any journal. The reviewers should follow a scientific and justifiable methodology for reviewing a case report for possible publication. Their comments should be constructive for the overall improvement of the manuscript and aid the editorial team in making a decision on publication. We hope this article will help reviewers to perform their important role in the best way possible. We send our best wishes to the reviewer community and, for those who are inspired to become reviewers after reading this article, our warm welcome to the reviewers’ club.

Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine. Plast Reconstr Surg. 2011;128:305–10.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Green BN, Johnson CD. How to write a case report for publication. J Chiropr Med. 2006;5:72–82.

Article   PubMed   PubMed Central   Google Scholar  

Abu-Zidan FM, Abbas AK, Hefny AF. Clinical “case series”: a concept analysis. Afr Health Sci. 2012;12:557–62.

CAS   PubMed   PubMed Central   Google Scholar  

Porta M, editor. A dictionary of epidemiology/edited for the International Epidemiological Association. 5th ed. UK: Oxford University Press; 2008. p. 33.

Medical Research Council of South Africa. Evidence-based medicine. 2016. http://www.mrc.ac.za/healthsystems/sai.htm . Accessed on 1 Nov 2015.

Cohen H. How to write a patient case report. Am J Health-Syst Pharm. 2006;63:1888–92.

Article   PubMed   Google Scholar  

Roberts LW, Coverdale J, Edenharder K, Louie A. How to review a manuscript: a “down-to-earth” approach. Acad Psychiatry. 2004;28:81–7.

Rutowski JL, Cairone JV. How to review scientific manuscripts and clinical case reports for Journal of Oral Implantology. J Oral Implantol. 2009;35:310–4.

Article   Google Scholar  

Jabs DA. Improving the reporting of clinical case series. Am J Ophthalmol. 2005;139:900–5.

Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D; CARE Group. The CARE guidelines: consensus-based clinical case reporting guideline development. BMJ Case Reports. 2013; doi: 10.1136/bcr-2013-201554 .

Download references

Author information

Authors and affiliations.

Department of Anaesthesiology, Pain and Palliative Care, DR BRAIRCH, AIIMS, Ansari Nagar, New Delhi, 110029, India

Rakesh Garg

Neurology and Medical Education, California University of Science and Medicine - School of Medicine, Colton, CA, USA

Shaheen E. Lakhan

Sandwell & West Birmingham Hospitals, NHS Trust, Birmingham, UK

Ananda K. Dhanasekaran

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Rakesh Garg .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors’ contributions

All authors read and approved the final manuscript.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Garg, R., Lakhan, S.E. & Dhanasekaran, A.K. How to review a case report. J Med Case Reports 10 , 88 (2016). https://doi.org/10.1186/s13256-016-0853-3

Download citation

Received : 27 August 2015

Accepted : 25 February 2016

Published : 06 April 2016

DOI : https://doi.org/10.1186/s13256-016-0853-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Journal of Medical Case Reports

ISSN: 1752-1947

  • Submission enquiries: Access here and click Contact Us
  • General enquiries: [email protected]

a case report example

  • Log In Username Enter your ACP Online username. Password Enter the password that accompanies your username. Remember me Forget your username or password ?
  • Privacy Policy
  • Career Connection
  • Member Forums

© Copyright 2024 American College of Physicians, Inc. All Rights Reserved. 190 North Independence Mall West, Philadelphia, PA 19106-1572 800-ACP-1915 (800-227-1915) or 215-351-2600

If you are unable to login, please try clearing your cookies . We apologize for the inconvenience.

Writing a Clinical Vignette (Case Report) Abstract

Case reports represent the oldest and most familiar form of medical communication. Far from a "second-class" publication, many original observations are first presented as case reports. Like scientific abstracts, the case report abstract is governed by rules that dictate its format and length. This article will outline the features of a well-written case report abstract and provide an example to emphasize the main features.

Scientific forums have specific rules regarding how the abstract should appear. For the ACP, the rules are available on the electronic abstracts portal. Organizers of scientific meetings set explicit limits on the length of abstracts.

The most difficult decision to make is whether your case report is worth submitting as an abstract. Of course, rarity of a condition almost always meets the criterion of worthiness, but few of us have the opportunity to describe something that is completely new. Another reason to report a case is the lesson that it teaches. With this in mind, consider presenting a case if it increases awareness of a condition, suggests the proper diagnostic strategy, or demonstrates a more cost-effective approach to management. Alternatively, a case can be presented because it represents an unusual presentation of a relatively common condition. Other twists include an unusual complication of a disease and its management. Again, it's important to think about the message or lesson that the case can deliver.

Before you begin writing the abstract, present a quick summary of your case to colleagues or mentors to determine if they agree that the case is worthy of presentation. It is important to contribute something unique, but not if it depends on some trivial variation from previously presented cases. For example, if it is known that a certain cancer widely metastasizes, it is not worthwhile to report each new site. Similarly, drug reactions often merit a case report, but not if it is simply a report of a drug in a class whose other members are known to cause the same reaction.

Once you have decided to submit a case report abstract, describe it in such a way as to make it interesting, yet conform to the accepted format. The following paragraphs provide suggestions on both style and format.

Title and Author Information: The title is a summary of the abstract itself and should convince the reader that the topic is important, relevant, and innovative. However, don't tell everything about the case in the title, otherwise the reader's interest might lag. Make the title short, descriptive, and interesting. Some organizations require a special format for the title, such as all uppercase letters. Be sure to check the instructions. Following the title, include the names of authors followed by their institutional affiliations. Deciding upon the authorship of a case report can be tricky. In the past, it was acceptable to include as authors those contributing to the management of the patient, but this is no longer true. Currently, it is expected that the authors contribute significantly to the intellectual content of the case report. It is assumed that the first author will present the work if the abstract is accepted. The first author may need to meet certain eligibility requirements in order to present the abstract, for example, be a member of the professional society sponsoring the research meeting. This information is always included with the abstract instructions.

Introduction: Most case report abstracts begin with a short introduction. This typically describes the context of the case and explains its relevance and importance. However, it is perfectly acceptable to begin directly with the description of the case.

Case Description: When reporting the case, follow the basic rules of medical communication; describe in sequence the history, physical examination, investigative studies, and the patient's progress and outcome. The trick is to be complete without obscuring the essence of the case with irrelevant details.

Discussion: The main purpose of the discussion is to review why decisions were made and extract the lesson from the case. Not uncommonly, reports from the literature, or their absence, are cited that either directly support or contradict the findings of the case. Be wary of boasting that your case is the "first" to describe a particular phenomenon, since even the most thorough searches often fail to reveal all instances of similar cases. Keep in mind that the best case report abstracts are those that make a small number of teaching points (even just one) in clear and succinct language.

When writing the abstract, avoid the use of medical jargon and excessive reliance on abbreviations. Limit abbreviations to no more than three, and favor commonly used abbreviations. Always spell out the abbreviations the first time they are mentioned unless they are commonly recognized (e.g., CBC).

It typically takes several days to write a good abstract, and the process should not be undertaken alone. Get help from a mentor who is not familiar with the case; such mentors can quickly point out areas that are unclear or demand more detail. Make revisions based upon the feedback. Finally, have others read your draft in order to check for technical errors, such as spelling and grammar mistakes. Reading the abstract out loud is another good way to catch awkward phrasing and word omissions. Finally, a Clinical Vignette Abstract Checklist  and an example of a clinical vignette abstract  are available to help you with the process of writing a successful abstract.

  • - Google Chrome

Intended for healthcare professionals

  • Access provided by Google Indexer
  • My email alerts
  • BMA member login
  • Username * Password * Forgot your log in details? Need to activate BMA Member Log In Log in via OpenAthens Log in via your institution

Home

Search form

  • Advanced search
  • Search responses
  • Search blogs
  • How to write a case...

How to write a case report

  • Related content
  • Peer review
  • Rahij Anwar , locum registrar in trauma and orthopaedics 1 ,
  • Huma Kabir , clinical fellow in paediatrics 2 ,
  • Rajesh Botchu , senior house officer in trauma and orthopaedics 3 ,
  • Shah Alam Khan , assistant professor 4 ,
  • Nitish Gogi , senior house officer in trauma and orthopaedics 5
  • 1 Royal London Hospital, Bexleyheath, London DA6 8DR
  • 2 Queen Mary's Hospital, Bexleyheath, London DA6 8DR
  • 3 Maidstone Hospital, Maidstone ME16 9PQ
  • 4 Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
  • 5 Russels Hall Hospital, Dudley DY1 2LU

Rahij Anwar and colleagues give advice on the practical details of writing case reports

Research has become an integral part of medical careers. A case report is a way of communicating information to the medical world about a rare or unreported feature, condition, complication, or intervention by publishing it in a medical journal.

When to start

Be on the look out for a case report from the start of your basic surgical or medical training. This will introduce you to the research world, and if your report is published it will be an asset to your CV. Any kind of research entails a lot of hard work and persistence. Your thought processes should be geared towards research in your postgraduate career, and you should use every opportunity you get for writing a report. So if you come across something unusual, discuss it with a consultant, particularly one who is keen on research.

Many consultants have huge amounts of material in the top drawers of their desks, waiting to be published. All they want is an enthusiastic medic who will help share their load in writing and getting it published. They are usually helpful if you ask them about this.

How to start

A senior doctor's help is a must from the beginning. He or she may know from their experience what cases are suitable for publication. Do an extensive literature search--PubMed, Medline, Ovid, Embase, and even search engines like Google will give you a vast amount of information related to the condition or feature you are after. Narrow down the search to your actual topic. If this comes up with very few search results, it means (assuming your search method is correct) that the case is rare and the report is therefore more likely to be published.

Your hospital library staff can help (especially in the beginning) by doing your searches for you and then getting relevant literature from other sources, if necessary. So don't be afraid to ask them. It is always useful to read in a standard textbook or appropriate journal everything about the topic that your case report relates to. Note down or photocopy important references at the end of the chapter or article and follow them up.

Obtaining consent from the patient is not only good medical practice but also mandatory for some journals, such as the BMJ (which has its own consent form on bmj.com). If there is no standard form, make up your own. It is useful to have the patient's contact details on the form just in case you want to trace him or her later. It is also polite to ask permission from the doctor in charge of the patient's management.

How to collect information related to the case

After you have done the groundwork, collect all the material for the case report. Use the patient's notes to record the details of all the events in the patient's care--that is, history, examination findings, results of investigations with dates, and operative findings, if any, together with the details of the actual intervention and follow ups. Get copies--do not take the originals (they are the patient's only records for future reference). You are allowed to have copies only of radiographs, slides, photographs, and so on, but in this electronic age it is better to use a digital camera for your personal copies of radiographs and clinical photographs. This avoids many potential problems and saves a lot of time. Make sure you return the notes and radiographs to their original source. You should also visit the patient again and make sure you have got the facts right.

Which journal to choose

Again, the advice of your supervising consultant is useful. Select a journal that you think would be the most appropriate for your case report. For example, unusual injury presentations are more likely to be accepted in the journals such as Trauma rather than more mainstream, general interest journal. The BMJ does not publish case reports, only Lesson of the Week. In other words, be sensible in choosing the journal.

Download or copy the information for authors for that particular journal and keep the hard copy safely in a folder with all the other information about the case. It is also useful to have a copy of any case report from a previous issue of the journal to get an idea of the presentation. It is extremely important to understand the basic format required by the journal. Your case report may be rejected because it does not conform to the standard format, no matter how good the content is. Margins, spacing, figure numbering, and style of references (Vancouver, Harvard, and so on), all are important aspects.

How many colleagues should be included?

The honest answer is not many: the supervising consultant and maybe one or two other colleagues, depending on how sincere and helpful they have been in collecting information or literature. You or your consultant (discuss with him or her) must be the first author. Do not ever give photographs or any other material related to your case report to anyone who you think might misplace them.

How do I write it?

It is best to write everything in one stretch. Piecemeal writing consumes time because you have to go over everything repeatedly. The following format is the most common way of writing a case report.

Introduction

Describe your case report in one sentence. Also mention how rare it is.

Case report

You have to summarise the information that you have gathered: a brief history and important and relevant positive and negative findings with details of investigations, treatment, and the condition of the patient after treatment. Don't include unnecessary details. Remember, this part should read like an interesting story, which your reader should enjoy.

One common form of presentation is to divide it into separate paragraphs with history, examination, investigation, treatment, and outcome in separate paragraphs--a textbook style of presentation without the headings.

Remember that the probability of getting any research work published in a reputable journal is determined primarily by how well your arguments are presented scientifically --that is, how your report is supported or discussed. The first paragraph may explain the objective of reporting the case.

You must subsequently describe whatothers have written before about the condition or any related feature. Be generous in quoting the literature but don't go into unnecessary details.

The third and most important stage in the discussion is to substantiate the message you are trying to convey. Your reviewers want proof of the rarity of the condition and the scientific explanations for it. If you don't do this, they are likely to reject your report immediately. So you must be able to describe the cause of the condition or why a particular procedure or feature was chosen. How did it influence the outcome? How does it differ from usual and what are your recommendations? Are there any lessons to be learnt? All (or at least, most) of these questions need to be answered in the discussion.

Box 1: Stages in writing a case report

Finding a rare case

Literature search

Collecting information related to the case, including consent

Summarising and writing

Revising and editing

Box 2: Format for writing a case report

the real story

Clinical features

Investigations

Treatment and outcome

review of literature

Recommendations, if any

This is not always necessary in a case report but if it is, summarise your message in a few sentences.

The reference section is boring and time consuming but extremely important. Keep to the style (Vancouver, Harvard, etc) that your journal requires. The references should be in the form of numbers as you go along (usually 1, 2, 3, etc, as superscripts or in brackets in the order of appearance, as required by your journal). It is useful to put the same number on your hard copy of the reference.

Finishing touches

Expect to have to edit and revise the report about three times. Make sure you use the spell and grammar check on your computer. Every section of the case report--discussion, reference, etc--should start on a new page. Get the senior author (usually supervising consultant) to review the finished report and then write a covering letter. All the other documents, including photographs, copyright, and so on, as required by the journal, should be attached to the final copy of the report before sending it to the journal.

You are allowed to have a party once you have put your completed case report in the mailbox. Not for celebration but for preparation. Your search for the next case report should start the next day.

Originally published as: Student BMJ 2004;12:60

a case report example

Visit us at Transform in Las Vegas, March 11-13, at Booth #14. Learn more or schedule a time to meet with us at the show here.

  • Resource Center

Investigation Report Example: How to Write an Investigative Report

Here’s how to write an investigation report that is clear, complete, and compliant.

Do you dread the end of an investigation because you hate writing investigative reports? You’re not alone.

However, because it’s an important showcase of the investigation, you can’t skimp on this critical investigation step. Your investigation report reflects on you and your investigation, so make sure it’s as clear, comprehensive, accurate, and polished.

How do you write an investigation report? What are the parts of an investigation report? What's an investigation report example? In this guide, you’ll learn how to make your reports effective and efficient.

How mature are your workplace investigations?

An investigations maturity model can reveal your investigations program's strong points and areas for improvement. Learn how to evaluate your program in our upcoming fireside chat with investigations expert Meric Bloch.

Table of Contents

What is the importance of an investigative report.

  • How to Write an Investigative Report: "Musts"

Executive Summary

Preliminary case information, incident summary, allegation subject, investigation details & notes, investigation interviews, conclusion & recommendations, final edits, how case iq can help.

An investigation report can:

  • Spark some sort of action based on the findings it presents
  • Record of the steps of the investigation
  • Provide information for legal actions
  • Provide valuable data to inform control and preventive measures

In short, your report documents what happened during the investigation and suggests what to do next.

In addition, the process of writing an investigation report can help you approach the investigation in a new way. You might think of more questions to ask the parties involved or understand an aspect of the incident that was unclear.

How to Write an Investigative Report: “Musts”

Before you begin, it’s important to understand the three critical tasks of a workplace investigative report.

  • It must be organized in a such way that anybody internally or externally can understand it without having to reference other materials. That means it should have little to no jargon or specialized language and be a stand-alone summary of your investigation from start to finish.
  • It must document the investigative findings objectively and accurately and provide decision makers with enough information to determine whether they should take further action.  With just one read-through, stakeholders should be able to understand what happened and how to handle it.
  • It must indicate whether the allegations were substantiated, unsubstantiated, or whether there’s something missing that is needed to reach a conclusion. Use the evidence you’ve gathered to back up your analysis.

You might be wondering, “What are the contents of an investigation report?” Now that you know what your report should accomplish, we’ll move on to the sections it should include.

Want to streamline the report-writing process?

Download our free investigation report template to ensure you have consistent, compliant, and complete reports for every case.

Get the Template

The executive summary should be a concise overview of the investigation from beginning to end. It should not contain any information that is not already in the investigation report.

This may be the most important component of the investigation report because many readers won’t need to go beyond this section. High-level stakeholders get an overall picture of the allegations, investigation, and outcome without having to pore over the details.

To make this section easy to read, write in an active voice. For example: “I interviewed Carrie Smith,” not “Carrie Smith was interviewed.”

Example:   On February 23 rd , 2023, the Human Resources Manager received a written complaint of sexual harassment submitted by Carrie Smith, the stockroom manager. Smith claimed that on February 22 nd , 2023, her supervisor, Mark Robinson, pushed her against the wall in the boardroom and groped her breasts. Smith also alleged that Robinson on another occasion told her she was “too pretty” to be working in the stockroom and that he could arrange for a promotion for her. 

On February 24th, the Human Resources Manager assigned the case to me.

On February 25th, I interviewed Carrie Smith and two witnesses to the alleged February 22 nd  incident, John Jones and Pamela Miller. Jones and Miller did not corroborate the groping allegation but said they saw Smith running out of the boardroom in tears. Miller also reported hearing Robinson tell another employee, Sara Brown, that she had “a great rack”. 

On February 26 th , I interviewed Mark Robinson. He denied the groping incident and said he was “just joking around” with her in the boardroom but did not actually touch her and that Smith was too sensitive. He admitted to telling Smith she was too pretty to work in the stockroom, but contends that it was meant as a compliment.

Based on the interviews with the complainant and the alleged offender, I find that the complainant’s allegation of sexual harassment is substantiated.

It is my recommendation that the company provide the respondent with a written account of the findings of the investigation and a reminder of the company’s expectations for employee behavior. I also recommend that the respondent receive sexual harassment training and be advised that repeated harassing behavior may result in further discipline up to and including termination.

This section outlines the preliminary case information in a concise format, with only the most important details. It can go either before or after the executive summary.

  • Your name and investigator identification number, if you have one
  • Case number
  • Date the case was assigned to you
  • The date the report was reviewed
  • How the report was received (e.g. hotline, email to HR manager, verbal report to supervisor)
  • Name of the reporter/complainant

If the reporter is an employee, record their:

  • Email address
  • Work telephone number
  • Employment level/position
  • Employee identification number
  • Department identification number

If the source  is not an employee, only record their:

  • Personal telephone number

In either case, note the date that the report was submitted, as well as the date(s) of the alleged incident(s).

The purpose of this section is to answer the who, what, where, and when about the incident.

  • What type of case is it? For example, is the case alleging harassment, discrimination, fraud, or other workplace misconduct?
  • Specify the case type further.  For example, is it  sexual  harassment,  gender  discrimination,  accounts payable  fraud, etc.
  • Who is the alleged victim?  For example, is it the reporter, another employee, a customer, or the whole company?
  • If the alleged victim is an employee, identify the person’s supervisor.
  • Were any other people involved besides the subject and the alleged victim?
  • Where did the incident(s) take place?
  • When did the incident(s) occur?
  • Capture details of the allegation.  Example : Stacey Smith alleges that John Jones, an accounts payables clerk, has been funneling payments to a dummy supplier that he has set up in the company’s procurement system. Stacey says that she noticed a discrepancy when one of the suppliers she deals with questioned a payment and she had to ask an accounts payable clerk, Tom Tierney, to pull the file for her. When Tom accidentally brought Stacey the wrong file, she saw that monthly payments were being made to a supplier she had never heard of, and that the address of the supplier was John Jones’s address. Stacey knows John’s address because her sister is John’s next-door neighbor.

Describe the allegation or complaint in simple, clear language. Avoid using jargon, acronyms, or technical terms that the average reader outside the company may not understand.

In this section, note details about the alleged bad actor. Some of this information might be included in the initial report/complaint, but others you might have to dig for, especially if the subject isn’t an employee of the organization.

For every subject, include their:

  • Email (work contact if they’re an employee, personal if not)
  • Telephone number (see above)

If the subject of the allegation is an employee, also include their:

  • Employment status (e.g. full-time, part-time, intern, contractor, etc.)
  • Business location

Begin outlining the investigation details by defining the scope. It’s important to keep the scope of the investigation focused narrowly on the allegation and avoid drawing separate but related investigations into the report.

Example:   The investigation will focus on the anonymous tip received through the whistleblower hotline. The objective of the investigation is to determine whether the allegation reported via the hotline is true or false.

Next, record a description of each action taken during the investigation. This becomes a diary of your investigation, showing everything that was done during the investigation, who did it, and when.

For each action, outline:

  • Type of action (e.g. initial review, meeting, contacting parties, conducting an interview, following up)
  • Person responsible for the action
  • Date when the action was completed
  • Brief description of the action (i.e. who you met with, where, and for how long)

Be thorough and detailed, because this section of your report can be an invaluable resource if you are ever challenged on any details of your investigation.

Write a summary of each interview. These should be brief outlines listed separately for each interview.

Include the following information:

  • Who conducted the interview
  • Who was interviewed
  • Where the interview took place
  • Date of the interview

Include a list of people who refused to be interviewed or could not be interviewed and why.

Write a Report for Each Interview

This is an expanded version of the summaries documented above. Even though some of the information is repeated, be sure to include it so that you can use the summaries and reports separately as standalone documentation of the interviews conducted.

For each interview, document:

  • Location of the interview
  • Summary of the substance of the interview, based on your interview notes or recording.

Example:   I asked Jane Jameson to describe the events of July 13 th , 2016. She said: “After work, Peter approached me as I was leaving the building and asked me if I would like to work on his team. When I said that I was happy working with my current team, he told me that my team had too many women on it and that ‘all those hormones are causing problems’ so I should think about moving to a ‘sane’ team.”

I asked her how she reacted to that. She said: I told him that I found that offensive and he said that I needed to stop being so sensitive. I just walked away.”

I asked Jane to describe the events of the next day. She said: “The next day he came to my desk and asked me if I had given any thought to moving to his team. I repeated that I was happy where I was. At that point he started massaging my shoulders and said that moving to his team would have its ‘perks’. I asked him to stop twice and he wouldn’t. Sally walked over and told him to get lost and ‘leave Jane alone’ and he left.”

I thanked Jane for her cooperation and concluded the interview.

Assess Credibility

Aside from collecting the evidence, it is also an investigator’s job to analyze the evidence and reach a conclusion. Include a credibility assessment for each interview subject in the interview report. Describe your reasons for determining that the interviewee is or isn’t a credible source of information.

This involves assessing the credibility of the witness. The EEOC has published guidelines that recommend examining the following factors:

  • Plausibility – Is the testimony believable and does it make sense?
  • Demeanor – Did the person seem to be telling the truth?
  • Motive to falsify – Does the person have a reason to lie?
  • Corroboration – Is there testimony or evidence that corroborates the witness’s account?
  • Past record – Does the subject have a history of similar behavior?

Example:   I consider Jane to be a credible interviewee based on the corroboration of her story with Sally and also because she has nothing to gain by reporting these incidents. She has no prior relationship with Peter and seemed genuinely upset by his behavior.

A well-written report is the only way to prove that an investigation was carried out thoroughly.

Download this free cheat sheet to learn best practices of writing investigation reports.

Get the Cheat Sheet

In this section, describe all the evidence obtained. This could include:

  • Video or audio footage
  • Email or messaging (e.g. Slack, Teams, etc.) records
  • Employee security access records
  • Computer or other device login records
  • Documents or papers
  • Physical objects (e.g. photos, posters, broken objects, etc.)

Number each piece of evidence for easy reference in your chain of evidence document.

As you gather and analyze evidence, it’s critically important to include and fully consider everything  you find. Ignoring evidence that doesn’t support your conclusion will undermine your investigation and your credibility as an investigator. If you aren’t weighing some pieces as heavily as others, make sure you have a good explanation as to why.

In the final section of your report, detail your findings and conclusion. In other words, answer the questions that your investigation set out to answer.

This is where your analysis comes into play. However, be sure to only address the issue(s) being examined only, and don’t include any information that is not supported by fact. Otherwise, you could be accused of bias or speculation if the subject challenges your findings.

Investigation Findings Example:   My findings indicate that, based on the evidence, Bill’s allegation that Jim blocked him from the promotion is true. Jim’s behavior towards Bill is consistent with the definition of racial discrimination. The company’s code of conduct forbids discrimination; therefore, Jim’s behavior constitutes employee misconduct.

It’s important for your conclusion to be defensible, based on the evidence you have presented in your investigation report. Reference reliable evidence that is relevant to the case. Finally, explain that you’ve considered all the evidence, not just pieces that support your conclusion.

In some cases, you might have been asked to provide recommendations, too. Depending on your conclusion, you may recommend that the company:

  • Does nothing
  • Provides counselling or training
  • Disciplines the employee(s)
  • Transfers the employee(s)
  • Terminates or demotes the employee(s)

Example: It is my recommendation that the company provide the respondent (Jim) with a written account of the findings of the investigation and a reminder of the company’s expectations for employee behavior. I also recommend that the respondent (Jim) receive anti-discrimination training and be advised that repeated discriminatory behavior may result in further discipline up to and including termination.

Grammatical errors or missed words can take even the best investigation report from professional to sloppy. That’s why checking your work before submitting the report is perhaps the most important step of them all.

Keep in mind that your investigative report may be seen by your supervisors, directors, and even C-level executives in your company, as well as attorneys and judges if the case goes to court.

If spelling, grammar, and punctuation aren’t your strong suit, enlist the services of a writer-friend or colleague to proofread your report. Or, if you’re a lone wolf kind of worker, upgrade your skills with a writing course or a read-through of books like  The Elements of Style by Strunk and White. At the very least, remember to run a spell check before you pass on any document to others.

Finally, do a quick scan to make sure you’ve included all the necessary sections and that case details are consistent.

Want more report-writing tips?

Watch our free webinar to get advice on what to include (and not include), proper language and tone, formatting tips, and more on how to effectively make an investigation report.

Watch the Webinar

If you’re still managing cases with spreadsheets or outdated systems, you’re putting your organization at risk.

With all your investigation information stored in one place, you can create comprehensive, compliant investigation reports with a single click. Case IQ’s powerful case management software pulls all the information from the case file automatically, so you can close cases faster.

Learn more about how Case IQ can reduce resolution time and improve your organization’s investigations here.

Related Resources

Lessons from fcpa settlements: investigations, remediations, and compliance programs, complying with the cfpb’s regulations for customer complaints.

Book cover

Acute Geriatric Care: from Hospital to Territorial Charge pp 9–12 Cite as

Case Report of Acute Elder Patients in Intensive Care Unit: Analysis of the Outcome and Recommendation

  • Nicola Vargas 4 ,
  • Andrea Fabbo 5 &
  • Antonio M Esquinas 6  
  • First Online: 23 February 2024

In this chapter, the authors describe a case report of the oldest old admitted to the ICU with a positive outcome. The oldest old may have a negative prognosis and increased mortality when admitted to the ICU. The authors have analyzed the factors at the base of the positive outcome to be included in evaluating the older patient before admission to the ICU.

  • Intensive care unit
  • Older patients

This is a preview of subscription content, log in via an institution .

Bagshaw SM, Webb SA, Delaney A, George C, Pilcher D, Hart GK, Bellomo R. Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis. Crit Care. 2009;13(2):R45. https://doi.org/10.1186/cc7768 .

Article   PubMed   PubMed Central   Google Scholar  

Flaatten H, Beil M, Guidet B. Elderly patients in the intensive care unit. Semin Respir Crit Care Med. 2021;42(1):10–9. https://doi.org/10.1055/s-0040-1710571 .

Article   PubMed   Google Scholar  

Ferrante LE, Pisani MA, Murphy TE, Gahbauer EA, Leo-Summers LS, Gill TM. Factors associated with functional recovery among older intensive care unit survivors. Am J Respir Crit Care Med. 2016;194(3):299–307. https://doi.org/10.1164/rccm.201506-1256OC .

Girard TD, Jackson JC, Pandharipande PP, et al. Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med. 2010;38(7):1513–20. https://doi.org/10.1097/CCM.0b013e3181e47be1 .

Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95.

Fernando SM, McIsaac DI, Rochwerg B, et al. Frailty and invasive mechanical ventilation: association with outcomes, extubation failure, and tracheostomy. Intensive Care Med. 2019;45(12):1742–52. https://doi.org/10.1007/s00134-019-05795-8 .

Boumendil A, Woimant M, Quenot JP, Rooryck FX, Makhlouf F, Yordanov Y, Delerme S, Takun K, Ray P, Kouka MC, Poly C, Garrouste-Orgeas M, Thomas C, Simon T, Azerad S, Leblanc G, Pateron D, Guidet B, ICE-CUB 2 Study Network. Designing and conducting a cluster-randomized trial of ICU admission for the elderly patients: the ICE-CUB 2 study. Ann Intensive Care. 2016;6(1):74. https://doi.org/10.1186/s13613-016-0161-5 .

Guidet B, Leblanc G, Simon T, Woimant M, Quenot JP, Ganansia O, Maignan M, Yordanov Y, Delerme S, Doumenc B, Fartoukh M, Charestan P, Trognon P, Galichon B, Javaud N, Patzak A, Garrouste-Orgeas M, Thomas C, Azerad S, Pateron D, Boumendil A, ICE-CUB 2 Study Network. Effect of systematic intensive care unit triage on long-term mortality among critically ill elderly patients in France: a randomized clinical trial. JAMA. 2017;318(15):1450–9. https://doi.org/10.1001/jama.2017.13889 .

Angus DC. Admitting elderly patients to the intensive care unit—is it the right decision? JAMA. 2017;318(15):1443–4. https://doi.org/10.1001/jama.2017.14535 .

Download references

Acknowledgments

The authors would like to thank Dr. Immacolata Alviggi, Geriatric and Intensive Geriatric Care, High Survey Hospital San Giuseppe Moscati, Avellino, Italy, and Dr. Federico Ruggiero, Department of Translational Medical Sciences, Federico II University, Naples, Italy, for their contribution to the development of the chapter.

Author information

Authors and affiliations.

Geriatric and Intensive Geriatric Care Unit, Medicine Department, Azienda Ospedaliera S.Giuseppe Moscati, Avellino, Italy

Nicola Vargas

Geriatric Service, Cognitive Disorders and Dementia Unit, Azienda USL Modena, Modena, Italy

Andrea Fabbo

Intensive Care Unit, Hospital General Universitario Morales M, Murcia, Spain

Antonio M Esquinas

You can also search for this author in PubMed   Google Scholar

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Cite this chapter.

Vargas, N., Fabbo, A., Esquinas, A.M. (2023). Case Report of Acute Elder Patients in Intensive Care Unit: Analysis of the Outcome and Recommendation. In: Acute Geriatric Care: from Hospital to Territorial Charge. Springer, Cham. https://doi.org/10.1007/978-3-031-48813-9_2

Download citation

DOI : https://doi.org/10.1007/978-3-031-48813-9_2

Published : 23 February 2024

Publisher Name : Springer, Cham

Print ISBN : 978-3-031-48812-2

Online ISBN : 978-3-031-48813-9

eBook Packages : Medicine Medicine (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

  • Publish with us

Policies and ethics

  • Find a journal
  • Track your research
  • Case Report Form: Types Uses & Template Examples

busayo.longe

Case report forms are one of the most important data instruments used for clinical researches and medical examinations. When conducting clinical trials, the researcher needs to record even the smallest of observations as they happen. A case report form is designed for this purpose.

In a case report form, you can track the unique changes of each research subject as the clinical trial progresses. This article will discuss different case report forms and show you how to create this form from scratch using Formplus. 

What is a Case Report Form? 

A case report form is an essential tool for clinical research, although it has been extended for use in other areas of medicine. Primarily, it is a record of all symptoms, signs, diagnosis, treatment, follow-up, observations, changes, and other important information from each research subject during clinical trials. The data gathered via case report forms (CRFs) are analyzed to arrive at the research results and draw valid conclusions. 

It is one of the most effective ways to systematically collect and store all the information from research for use. For example, during clinical trials to test the efficacy of a drug, you need to collect data at every stage of the process to answer all your research questions. 

In a broader sense, a case study is a questionnaire used for collecting data from patients in the course of any medical procedure, including diagnoses and treatments. It provides valid information that makes up the patient’s medical history which can be used for medical research.

Importance of a Case Report Form  

  • It provides valid information for hypothesis-testing during clinical research. 
  • A case report form captures standardized clinical data at every stage of the research process. This data is analyzed to arrive at research outcomes.
  • Case report forms play an essential part in medical research breakthroughs. By storing unique data from each research subject, case report forms create a large pool of verifiable medical research information. 
  • It improves problem-based medical education. 
  • Data from case report forms make up a large chunk of peer-reviewed journals in medical research. 
  • Medical researchers leverage existing data from different case report forms to advance systematic investigations in specific fields and sub-fields.
  • Data from case report forms have helped us develop treatments and vaccines for different diseases, viruses, and infections. 

Types of Case Report Form  

Paper case report form.

A paper case report form is the traditional method of collecting data during clinical trials. It is the use of paper questionnaires and paper-based systems to gather detailed information from research subjects as per the study protocol. This data is extracted, organized and analyzed to arrive at valid research outcomes. 

Advantages of Paper Case Report Forms

  • It is relatively easier to create and implement paper case report forms. 
  • It allows you to collect research data in remote areas without electricity supply and internet access. 

Disadvantages of Paper Case Report Forms

  • Data loss due to theft and exposure to natural elements like fire outbreaks and floods. 
  • It is difficult to organize and analyze large volumes of data. 
  • When dealing with large volumes of information, it can be challenging to sort the data sets. 
  • It is time-consuming and prone to errors. 

Electronic Case Report Form

An electronic case report form is an online questionnaire used for data collection in medical studies and clinical trials. This method of data collection in medical research was introduced in the late 1990s following the shortcomings of paper forms. Electronic case report forms support more accurate data collection and faster data processing. 

Advantages of Electronic Case Report Forms

  • It allows for faster data collection; especially when you are dealing with large volumes of data. 
  • It reduces data losses, errors and costs. 
  • ECRFs allow you to share data remotely among different stakeholders in the research process. 
  • It facilitates rapid data capture and data management. 
  • Easy and transparent access to research data at all times. 

Disadvantage of Electronic Case Report Forms

  • High costs depending on the complexity of the electronic case report form.

Case Report Form Template Examples  

  • Case Report Form

Use this case report form from Formplus to collect specific data from patients as part of the standard medical research procedure. With this survey, you can gather all the important information you need from the patients at once, and then go ahead with a proper diagnosis.

  •   Health Care Proxy Form

The Formplus health care proxy form serves as a legal document for individuals who want to empower others to make decisions for them when they are sick or unavailable. With this form, individuals can formally select their health care providers to act on their behalf when the need arises. You can also edit this proxy form to suit unique needs in the form builder.

  • Medical Information Form

With the Formplus medical information form, patients can easily keep track of their health status by having all the information they need in one place. This form collects relevant information about the individual’s medical history, bio-data and doctor’s contact information in case of emergency. 

  • Clinical Report Form

Are you conducting any type of clinical research? This form will help you to seamlessly gather and analyze all the data you need for your systematic investigation. While this is a template, you can always edit it to suit your needs using the different features in our drag-and-drop form builder.

  •    Physical Examination Report Form

As you conduct physical examination of your patient, you can put all the information you gather in a Formplus physical examination form. This form allows you to collect data like the gender, weight, blood pressure and height of the patient. Our physical examination form makes it easy to document the patient’s health history. 

  • Self Report Form

To make it easier for patients to check for symptoms and monitor their health, you can edit this self-report form and embed it on your hospital’s website for easy access. With this form, health officials and medical practitioners can keep track of and monitor the health status of their patients and employees if the need arises.

Why Use Formplus to Create a Case Report Form? 

A case report form can be administered as a paper form or an online form; that is, ECRF. Data collection platforms like Formplus allow you to create secure online CRFs with data validation and data export features. You can also generate reports from the data in the form analytics dashboard.

  • Collect Data Anywhere : Formplus allows you to collect research data in locations with poor or no internet connection using offline forms. The information filled into the case report form is automatically updated on our servers or your preferred cloud storage system once internet access is restored. 
  • Collect Data on Mobile Devices: You don’t need to have a laptop to record responses on your Formplus form. All Formplus forms are mobile-friendly and allow you to fill in responses from your smartphone. This allows you to record data on the go as you conduct clinical trials. 
  • Analyze Data Easily : In the form analytics dashboard, you can access important insights about your data and data collection process. You can automatically generate custom visual reports for your form data using the reports summary tool available in Formplus. With just a few clicks, this tool instantly displays selected form fields and form data as custom graphs and charts.
  • Add Multiple Form Fields : With more than 30 form fields, you can collect different types of information in your electronic case report form, seamlessly. You can add long text fields for open-ended questions and different types of scales and radio fields for closed-ended questions. 
  • Export Data : Formplus allows you to export research data to other file formats including CSV, PDF and Google sheets. This makes it easier for you to collaborate with others and share data from your online case report form easily. 
  • Teams and Collaboration: With teams and collaboration, you can easily keep all the members of your research team in sync as you work on forms, data, and responses. Formplus allows you to add important collaborators to your shared account so that everyone can have access to the clinical trials reports in real-time. 

How to Create Electronic Case Report Forms With Formplus

1. Create a free Formplus account on www.formpl.us . Then log into your new account to view your dashboard. 

a case report example

2. Click on the “create new form” button to access the Formplus dashboard. 

a case report example

3. In the Formplus dashboard, you can add multiple fields to the online case report form. Drag and drop the fields you want from the builder’s fields section into your form. 

a case report example

4. Edit the form fields to include your question, options and other information. Here, you can also set the fields as required or read-only. 

5. Save all the changes you’ve made to access the form customization section. Use the different features and options to tweak the look and feel of your case report form. 

6. Copy the form link and share with respondents. 

a case report example

Conclusion  

In this article, we have looked at different types and use-cases for case report forms. As a researcher, it is best to use electronic CRFs that reduce your risk of data losses and help you record information faster. 

When you sign up for a Formplus account, you can access different case report form templates to help your research. From medical information surveys to health care proxy forms, you are sure to find a template that suits your research purpose. In the form builder, you can edit these templates to align them with your research goals. 

Logo

Connect to Formplus, Get Started Now - It's Free!

  • case report form
  • compatibility questionnaires
  • complaint form
  • contact form builder
  • incident report
  • incident report form template
  • Lead Generation Forms
  • Online Forms
  • busayo.longe

Formplus

You may also like:

How to Create HTML Contact Forms on a WordPress Website

Learn how to design a beautiful contact form on your “contact us” page with a Contact Form Builder. You don’t need CSS or HTML skills to...

a case report example

How to Write a Complaint Letter + [ 5 Template Samples]

A simple guide to writing a complaint letter & how employers and management can receive feedback your products & services

Top 20 Best Online Form Builders in 2019 | Create Beautiful Forms

Review of the best online form builders for data collection used to create HTML web forms with database without Coding experience. 1....

Incident Report: Examples, Form Templates & Writing Guide

Simple guide on incident report, letter samples, form templates and how to write a typical incident report letter

Formplus - For Seamless Data Collection

Collect data the right way with a versatile data collection tool. try formplus and transform your work productivity today..

U.S. flag

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

  • Publications
  • Account settings
  • Advanced Search
  • Journal List
  • Indian Dermatol Online J
  • v.12(5); Sep-Oct 2021

How to Write a Case Report?

Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India

Inderpal Singh

1 Department of Dermatology, Maharishi Markandeshwar Medical College, Sultanpur Road, Himachal Pradesh, India

Case report is regarded as one of the first line of evidence in medical science. There have been numerous circumstances, where the initial dissemination (and breakthrough) of scientific knowledge had been done, with the help of case reports. Case report is a particular variety of manuscript that showcases the unusual features and management of a patient. The words of William Osler (Father of modern medicine) “Always note and record the unusual…publish it. Place it on permanent record as a short, concise note. Such communications are always of value,” still hold relevance in today's era. In this article, we shall discuss the keys to draft a case report worthy of publication.

Case report is a distinct way of conveying a piece of information.[ 1 ] In addition, writing a case report provides a good opportunity to young physicians to get acquainted with the nitty gritties of writing a scientific article.[ 2 ] Case reports have more chances of acceptance if they provide a message which has the ability to alter clinical practice. They are also accepted if they add to the existing literature and/or raise a novel research question, which has the potential of generating a large-scale research.[ 3 , 4 ]

A case report is expected to be authentic and thought provoking. The use of propranolol for the management of infantile hemangiomas is an example; which came into limelight with the publication of case reports; and thereafter, large-scale experimental studies were designed.[ 5 , 6 , 7 ] Therefore, case reports aid in designing tenable protocol for performing good quality scientific research.[ 8 ] The CARE (CAse REport) guidelines for writing a case report are universally followed.[ 9 ]

Brevity and clarity, are the two pre-requisites for any case report.[ 9 ] The various components of a case report and the preferable formatting of the same have been summarized below:

  • Title : Authors should attempt to provide a short and crisp title, and ensure that the title attracts the reviewers, editors, and the readers, to go through the entire article. The title should be well-thought of and comprehensive. It should always give a fair idea of what lies within the article, and should not be vague and non-specific. The new message of the article should preferably be reflected in the title. Most importantly, the title should be scientifically sound. Abbreviations in the first place should be avoided, and authors should avoid the use of “superfluous words”.
  • Abstract : The abstract must clearly state the new information and the key takeaway messages.[ 10 ] There should be adequate patient data in terms of relevant history, clinical findings, tests, and interventions. Both physician and patient assessed outcomes should be mentioned.[ 11 ] Abstract is one of the most crucial components of an article, because, the reviewers and the editors would be having a fair perception of the entire manuscript after reading the abstract, and many times, the articles get rejected due to a poorly written abstract (lack of flow and message). Abstract should be revised every time the manuscript is revised or changed.
  • Keywords : Choosing a proper keyword is very important, while writing a case report. Keywords aid the indexers and search engines find relevant papers. Keywords should represent the content of the manuscript, and should be specific to the entity in question
  • Introduction : Introduction of a case report must initially address the magnitude and importance of the disease in question. Authors should highlight as to what is unknown about the entity and why they are reporting the case.
  • Case report : This section should describe all the necessary details of the patient including de-identified patient-specific information, concerns, and symptoms, relevant history (medical, surgical, and family), significant clinical examination findings (both positive and negative), diagnostic tests, differentials, provisional diagnosis, and prognosis. Authors should always mention how they ruled out the clinical and histpathological differentials (preferably in a tabular format) and how they arrived at the final diagnosis. If applicable, authors should also describe the details of therapeutic intervention (pharmacological name of drug, dose, frequency and duration). The response to treatment (objective and subjective parameters) must be mentioned clearly, without any ambiguity. When the authors are reporting a drug reaction, it is advisable to mention the details of Naranjo's adverse drug reaction probability scale, Hartwig's severity assessment scale and modified Schumock and Thornton scale. Besides, it is prudent to register the drug reaction under Pharmacovigilance Program of India (PvPI) and mention the necessary details about the same, in the case report.
  • Discussion : The discussion should include the relevant medical literature and the rationale for the conclusion. It is always advisable to add the perspective of the patients, whenever possible.[ 12 ] A thorough literature search must be done and the relevant references must be cited. Some widely used reference management and formatting software applications are BibTeX, Papers, Zotero, EndNote, RefWords, ReadCube, and Mendeley. Authors should always avoid the claims the first publication, because this is not possible to be verified by the reviewers and editors, and such claims are not desirable while publishing any article. Authors should summarize the key findings and unique points about their case, highlighting the need for publishing the case report (as to how this will add to the literature). The primary take-away messages of the case report should be given at the end of the article, in the form of a one-line conclusion.
  • Images and figures : The requirements are always mentioned in the website of the journal. Some of the vital considerations include a non-identifiable patient, high-quality JPEG or TIFF-centered clear and sharply focused images, and not exceeding 3-4 MB. Authors should never crop the original image, and ensure that the background is clean. If the figure has been published before, authors should acknowledge the original source and submit written permission from the copyright holder to reproduce the material. A credit line should appear in the legend for such figures. Low-resolution images, grainy images due to high ISO and pixelated images should never be submitted. The photographs must be clicked in a manner that makes it clear to the readers, as to which region is involved. If the authors are describing a case whose uniqueness lies in the unilateral distribution of lesions on the lower limb, the photograph must be clicked in a fashion which displays both the lower limbs. When it comes to therapeutic interventions, the pre-treatment and post-treatment photographs should have the same resolution, exposure, brightness and background. The figure legends must precisely mention about the stain and magnification for dermatopathology images; and the type of dermoscope used (and the magnification).[ 13 ]

Apart from the aforementioned things, some of the important issues which need to be taken care of, include informed consent by the patient, potential conflicts of interest, de-identification of patient-related data, and ethics committee approval, if obtained or necessary.[ 14 , 15 ] We propose the format as shown in Apppendix 1 for case report. This worksheet can streamline the process of writing, by providing a structure. Once completed, it can be quickly formatted into a manuscript for submission. We believe that this worksheet will serve as a handy tool for penning down case reports. The greatest barrier is paucity of time, and a certain anxiety about the process of publication. Following a structured standard approach to organizing and presenting clinical observations, may remove these barriers for busy physicians who are genuinely interested in writing case reports.

Most authors, reviewers and editors are of the opinion, that authors should strictly follow the instructions pertaining to preparation of manuscript so as to increase the probability of acceptance of manuscript. Authors may either follow the instructions which are available on the specific website of the journal, or they can also follow the guidelines which are uniformly followed by all biomedical journals ( http://www.icmje.org/index.html ). Manuscripts are often rejected outright by the journals, when the instructions are not followed properly.[ 10 ]

An accurate, thoroughly worked-up and well-written case report strengthens the medical literature. Therefore, authors must strictly follow the instructions while preparing the draft of the case report – comprehensive, crisp, and apt, and most importantly, the ability to add to clinical practice.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Appendix 1: Case report check sheet

Advertisement

The Civil Fraud Ruling on Donald Trump, Annotated

By Kate Christobek

Former President Donald J. Trump was penalized $355 million , plus millions more in interest, and banned for three years from serving in any top roles at a New York company, including his own, in a ruling on Friday by Justice Arthur F. Engoron. The decision comes after the state's attorney general, Letitia James, sued Mr. Trump, members of his family and his company in 2022.

The ruling expands on Justice Engoron’s decision last fall , which found that Mr. Trump’s financial statements were filled with fraudulent claims. Mr. Trump will appeal the financial penalty and is likely to appeal other restrictions; he has already appealed last fall’s ruling.

The New York Times annotated the document.

Download the original PDF .

Page 1 of undefined PDF document.

New York Times Analysis

This ruling by Justice Arthur F. Engoron is a result of a 2022 lawsuit filed by New York’s attorney general, Letitia James , against Donald J. Trump and the Trump Organization; his adult sons, Donald Trump Jr. and Eric Trump; the company’s former chief financial officer Allen Weisselberg and former controller Jeffrey McConney; and several of their related entities. Mr. Trump’s daughter, Ivanka Trump, was also initially a defendant until an appeals court dismissed the case against her.

Page 2 of undefined PDF document.

The law under which Ms. James sued, known by its shorthand 63(12), requires the plaintiff to show a defendant’s conduct was deceptive . If that standard is met, a judge can impose severe punishment, including forfeiting the money obtained through fraud. Ms. James has also used this law against the oil company ExxonMobil, the tobacco brand Juul and the pharma executive Martin Shkreli.

Page 4 of undefined PDF document.

Justice Engoron is now providing a background of this case. This ruling comes after a three-year investigation by the attorney general’s office and the conclusion of a trial that ended last month. But this likely won’t be Mr. Trump’s last word on the matter — he will appeal the financial penalty and is likely to appeal other restrictions, as he has already appealed other rulings.

In late 2022, Justice Engoron assigned a former federal judge, Barbara Jones, to serve as a monitor at the Trump Organization and tasked her with keeping an eye on the company and its lending relationships. Last month, she issued a report citing inconsistencies in its financial reporting, which “may reflect a lack of adequate internal controls.”

Page 5 of undefined PDF document.

Here, Justice Engoron is laying out the laws he considered in his ruling beyond 63(12). The attorney general’s lawsuit included allegations of violations of falsifying business records, issuing false financial statements, insurance fraud and related conspiracy offenses.

Justice Engoron is explaining the decision, issued a week before the trial, in which he found that Mr. Trump’s financial statements were filled with fraud , fundamentally shaping the rest of the trial.

Page 6 of undefined PDF document.

For over 50 pages, Justice Engoron describes his conclusions about the testimony of all of the witnesses who spoke during the trial.

Page 8 of undefined PDF document.

Justice Engoron discusses Mr. McConney’s important role in preparing Mr. Trump’s financial statements. The judge points out that Mr. McConney prepared all the valuations on the statements in consultation with Mr. Weisselberg.

Page 24 of undefined PDF document.

In his discussion of Mr. Weisselberg, Justice Engoron calls his testimony in the trial “intentionally evasive.” Justice Engoron then brings up Mr. Weisselberg’s separation agreement from the Trump Organization, which prohibited him from voluntarily cooperating with any entities “adverse” to the organization. Justice Engoron says that this renders Mr. Weisselberg’s testimony highly unreliable.

Page 27 of undefined PDF document.

When Donald Trump Jr. testified in court, he disavowed responsibility for his father’s financial statements despite serving as a trustee of the Donald J. Trump Revocable Trust while his father was president. But Justice Engoron specifically cites here that Donald Trump Jr. certified that he was responsible for the financial statements, and testified that he intended for the banks to rely on them and that the statements were “materially accurate.”

Page 30 of undefined PDF document.

During his testimony, Eric Trump, the Trump Organization’s de facto chief executive, initially denied knowing about his father’s financial statements until this case. As Justice Engoron points out here, Eric Trump eventually conceded to knowing about them as early as 2013. As a result, Justice Engoron calls Eric Trump’s credibility “severely damaged.”

Page 33 of undefined PDF document.

Justice Engoron points to Mr. Trump’s testimony when he took the witness stand in November when Mr. Trump acknowledged that he helped put together his annual financial statements. Mr. Trump said he would see them and occasionally have suggestions.

Page 35 of undefined PDF document.

After four pages of describing Mr. Trump’s testimony, Justice Engoron says Mr. Trump rarely responded to the questions asked and frequently interjected long, irrelevant speeches, which all “severely compromised his credibility.”

Page 38 of undefined PDF document.

For several pages, Justice Engoron provides background on specific assets that Mr. Trump included in his annual financial statements.

Page 61 of undefined PDF document.

The judge is clarifying that Ms. James had to prove her claims by a “preponderance of the evidence,” meaning she had to demonstrate it was more likely than not that Mr. Trump and the co-defendants should be held liable. This is a lower standard than that of a criminal trial, which requires that evidence be proven “beyond a reasonable doubt.”

Page 76 of undefined PDF document.

During the trial, Mr. Trump and his legal team tried to shift the blame for any inaccuracies in his financial statements onto his outside accountants. But Justice Engoron criticizes that argument here.

Page 77 of undefined PDF document.

During the monthslong trial, Mr. Trump, his legal team and several witnesses stressed that real estate appraisals are an art, not a science. But here it’s clear Justice Engoron, while agreeing with that sentiment, also believes it’s deceptive when different appraisals rely on different assumptions.

Page 78 of undefined PDF document.

Justice Engoron is now going through the defendants one by one and articulating the evidence that shows each of their “intent to defraud,” which is required by the statute against falsifying business records. Notably, his first paragraph describing the former president’s intent provides examples including Mr. Trump’s awareness that his triplex apartment was not 30,000 square feet and his valuation of Mar-a-Lago as a single-family residence even though it was deeded as a social club.

Page 79 of undefined PDF document.

Among the defendants, Justice Engoron finds only Allen Weisselberg and Jeffrey McConney liable for insurance fraud. Here, he doesn’t provide an explanation for why the other defendants, including Mr. Trump and his adult sons, were not found liable, and he says that both Mr. Weisselberg and Mr. McConney made false representations to insurance companies about Mr. Trump’s financial statements.

While Mr. Trump and his adult sons were not found liable for insurance fraud, here Justice Engoron finds them liable for conspiracy to commit insurance fraud, explaining that they all “aided and abetted” the conspiracy to commit insurance fraud by falsifying business records.

Page 82 of undefined PDF document.

Justice Engoron here adopts the approximations of Michiel McCarty, the attorney general’s expert witness. Justice Engoron says Mr. McCarty testified “reliably and convincingly,” and finds that the defendants’ fraud saved them over $168 million in interest.

Page 83 of undefined PDF document.

In finding that the defendants were able to purchase the Old Post Office in Washington, D.C., through their use of the fraudulent financial statements, Justice Engoron rules that the defendants’ proceeds from the sale of the post office in 2022 should be considered “ill-gotten gains.” He penalizes Donald Trump and his companies over $126 million, and Donald Trump Jr. and Eric Trump $4 million each, for this one property.

Page 84 of undefined PDF document.

Justice Engoron blasts the defendants for failing to admit that they were wrong in their valuations — adding that “their complete lack of contrition and remorse borders on pathological.” He says that this inability to admit error makes him believe they will continue their fraudulent activities unless “judicially restrained.”

Page 88 of undefined PDF document.

The judge cites other examples of Mr. Trump’s “ongoing propensity to engage in fraud,” bringing up lawsuits against Trump University and the Donald J. Trump Foundation. He also notably raises two criminal cases brought by the Manhattan district attorney’s office: one against Mr. Weisselberg, who pleaded guilty to tax fraud and falsifying business records , and another against the Trump Organization, which was convicted of 17 criminal counts including tax fraud .

Justice Engoron states that Judge Barbara Jones, who has been serving as an independent monitor at the Trump Organization since 2022, will continue in that role for at least three years. He clarifies that going forward, her role will be enhanced and she will review Trump Organization financial disclosures before they are submitted to any third party, to ensure that there are no material misstatements.

Page 89 of undefined PDF document.

In addition to extending the monitor’s tenure and strengthening her powers, Justice Engoron also took the unusual step of ordering that an independent compliance director be installed inside The Trump organization, and that they report directly to the monitor.

— William K. Rashbaum

In his pre-trial order, Justice Engoron ordered the cancellation of some of Mr. Trump’s business licenses . But here, he pulls back on that decision and instead says that any “restructuring and potential dissolution” would be up to Ms. Jones, the independent monitor.

Page 90 of undefined PDF document.

Justice Engoron lays out his bans against the defendants, ruling that Mr. Trump, Mr. Weisselberg and Mr. McConney cannot serve as officers or directors of any corporation or legal entity in New York for the next three years, and bans his sons Donald Trump Jr. and Eric Trump for two years from the same. He also prohibits Mr. Trump from applying for any loans from any New York banks for the next three years. The ruling goes further in the cases of Mr. Weisselberg and Mr. McConney, permanently barring them from serving in the financial control function of any New York business.

Page 91 of undefined PDF document.

Justice Engoron also ordered that Mr. Trump and his sons pay the interest, pushing the penalty to $450 million, according to Ms. James.

Page 92 of undefined PDF document.

An earlier version of this article misstated how long the adult sons of former President Donald J. Trump — Donald Trump Jr. and Eric Trump — were barred by Justice Arthur F. Engoron from serving as officers or directors of any corporation or legal entity in New York. It was two years, not three. The article also misstated the number of pages in which Justice Engoron describes his conclusions about the testimony of all of the non-defendant witnesses. It was under 50 pages, not over 50 pages. The article also misstated the number of pages in the section in which Justice Engoron provides background on specific assets that Mr. Trump included in his annual financial statements. It was several pages, not more than a dozen pages.

  • Share full article

Examples logo

Accomplishment Report for Remedial Classes

accomplishment

This report aims to highlight the significant progress and achievements made in the remedial classes conducted at Springfield Community School during the academic year 2023-2024. Designed to support students who required additional help in English and Mathematics, the remedial program has successfully enhanced student understanding and academic performance in these subjects.

Program Overview

Duration: September 2023 – June 2024 Subjects Covered: English and Mathematics Participants: 45 students from Grades 6 to 8 Instructors: 3 certified remedial teachers Methodology: Individualized instruction, peer tutoring, interactive learning sessions

  • Improve students’ proficiency in English and Mathematics.
  • Enhance students’ confidence in their academic abilities.
  • Provide personalized support to address specific learning gaps.

Accomplishments

  • Increased Proficiency: Post-assessment results showed an average improvement of 35% in Mathematics and 40% in English among participants.
  • Enhanced Participation: Student engagement in regular classes improved, with a noticeable increase in class participation and homework completion rates.
  • Positive Feedback: 90% of students reported feeling more confident in their abilities to tackle challenging subjects.
  • Parental Involvement: Achieved a 75% increase in parental involvement in students’ academic lives through regular updates and workshops.

Case Studies

  • Student A: Improved from a C- to a B+ in Mathematics, demonstrating significant understanding in algebraic concepts previously struggled with.
  • Student B: Exhibited remarkable progress in English comprehension and writing, advancing two reading levels by the end of the program.

Challenges Encountered

  • Initial resistance from students due to stigma associated with remedial classes.
  • Adapting teaching methods to suit varied learning styles and paces.

Strategies Implemented

  • Integration of technology and gamification to make learning more engaging.
  • Regular motivational sessions and success stories to boost morale and participation.

The Remedial Classes Program at Springfield Community School has substantially contributed to the academic and personal growth of participating students. By providing targeted support and fostering a positive learning environment, we have witnessed remarkable improvements in students’ confidence and academic performance. Moving forward, we aim to refine our strategies, expand our reach, and continue making a profound impact on students’ educational journeys.

Future Directions

  • Introduction of more interactive learning tools and resources.
  • Expansion of the program to include more subjects and grade levels.
  • Strengthening collaboration with parents and the wider school community to support student learning.

Acknowledgments

We extend our deepest gratitude to the school administration, dedicated instructors, supportive parents, and hardworking students, whose collective efforts made these achievements possible.

Prepared by: [Instructor’s Name] [Position] [Date]

a case report example

AI Generator

Text prompt

  • Instructive
  • Professional

10 Examples of Public speaking

20 Examples of Gas lighting

Case report

Reproductive Health welcomes well-described reports of cases involving reproductive organs or diseases/conditions that include the following: • Unreported or unusual side effects or adverse interactions involving medications • Unexpected or unusual presentations of a disease. • New associations or variations in disease processes. • Presentations, diagnoses and/or management of new and emerging diseases. • An unexpected association between diseases 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. Case reports submitted to Reproductive Health should make a contribution to medical knowledge and must have educational value or highlight the need for a change in clinical practice or diagnostic/prognostic approaches. Reproductive Health will not consider Case reports describing preventive or therapeutic interventions, as these generally require stronger evidence. Case reports should include relevant positive and negative findings from history, examination and investigation, and can include clinical photographs, provided these are accompanied by written consent to publish from the patient(s). Case reports should include an up-to-date review of all previous cases in the field. Authors are encouraged to describe how the Case report is rare or unusual as well as its educational and/or scientific merits in the covering letter that will accompany the submission of the manuscript. Case report submissions will be assessed by the Editors and will be sent for peer review if considered appropriate for the journal. Authors should seek written and signed consent to publish the information from the patients or their guardians prior to submission. The submitted manuscript must include a statement to this effect in the Consent section. The editorial office may request copies of the informed consent documentation upon submission of the manuscript.

Preparing your manuscript

The information below details the section headings that you should include in your manuscript and what information should be within each section.

Please note that your manuscript must include a 'Declarations' section including all of the subheadings (please see below for more information).

Title page 

The title page should:

  • "A versus B in the treatment of C: a randomized controlled trial", "X is a risk factor for Y: a case control study", "What is the impact of factor X on subject Y: A systematic review, A case report etc."
  • or, for non-clinical or non-research studies: a description of what the article reports
  • if a collaboration group should be listed as an author, please list the Group name as an author. If you would like the names of the individual members of the Group to be searchable through their individual PubMed records, please include this information in the “Acknowledgements” section in accordance with the instructions below
  • Large Language Models (LLMs), such as ChatGPT , do not currently satisfy our authorship criteria . Notably an attribution of authorship carries with it accountability for the work, which cannot be effectively applied to LLMs. Use of an LLM should be properly documented in the Methods section (and if a Methods section is not available, in a suitable alternative part) of the manuscript
  •  indicate the corresponding author

The Abstract should not exceed 350 words. Please minimize the use of abbreviations and do not cite references in the abstract. The abstract must include the following separate sections:

  • Background: why the case should be reported and its novelty
  • Case presentation: a brief description of the patient’s clinical and demographic details, the diagnosis, any interventions and the outcomes
  • Conclusions: a brief summary of the clinical impact or potential implications of the case report

Keywords 

Three to ten keywords representing the main content of the article.

The Background section should explain the background to the case report or study, its aims, a summary of the existing literature.

Case presentation

This section should include a description of the patient’s relevant demographic details, medical history, symptoms and signs, treatment or intervention, outcomes and any other significant details.

Discussion and Conclusions

This should discuss the relevant existing literature and should state clearly the main conclusions, including an explanation of their relevance or importance to the field.

List of abbreviations

If abbreviations are used in the text they should be defined in the text at first use, and a list of abbreviations should be provided.

Declarations

All manuscripts must contain the following sections under the heading 'Declarations':

Ethics approval and consent to participate

Consent for publication, availability of data and materials, competing interests, authors' contributions, acknowledgements.

  • Authors' information (optional)

Please see below for details on the information to be included in these sections.

If any of the sections are not relevant to your manuscript, please include the heading and write 'Not applicable' for that section. 

Manuscripts reporting studies involving human participants, human data or human tissue must:

  • include a statement on ethics approval and consent (even where the need for approval was waived)
  • include the name of the ethics committee that approved the study and the committee’s reference number if appropriate

Studies involving animals must include a statement on ethics approval and for experimental studies involving client-owned animals, authors must also include a statement on informed consent from the client or owner.

See our editorial policies for more information.

If your manuscript does not report on or involve the use of any animal or human data or tissue, please state “Not applicable” in this section.

If your manuscript contains any individual person’s data in any form (including any individual details, images or videos), consent for publication must be obtained from that person, or in the case of children, their parent or legal guardian. All presentations of case reports must have consent for publication.

You can use your institutional consent form or our consent form if you prefer. You should not send the form to us on submission, but we may request to see a copy at any stage (including after publication).

See our editorial policies for more information on consent for publication.

If your manuscript does not contain data from any individual person, please state “Not applicable” in this section.

All manuscripts must include an ‘Availability of data and materials’ statement. Data availability statements should include information on where data supporting the results reported in the article can be found including, where applicable, hyperlinks to publicly archived datasets analysed or generated during the study. By data we mean the minimal dataset that would be necessary to interpret, replicate and build upon the findings reported in the article. We recognise it is not always possible to share research data publicly, for instance when individual privacy could be compromised, and in such instances data availability should still be stated in the manuscript along with any conditions for access.

Authors are also encouraged to preserve search strings on searchRxiv https://searchrxiv.org/ , an archive to support researchers to report, store and share their searches consistently and to enable them to review and re-use existing searches. searchRxiv enables researchers to obtain a digital object identifier (DOI) for their search, allowing it to be cited. 

Data availability statements can take one of the following forms (or a combination of more than one if required for multiple datasets):

  • The datasets generated and/or analysed during the current study are available in the [NAME] repository, [PERSISTENT WEB LINK TO DATASETS]
  • The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
  • All data generated or analysed during this study are included in this published article [and its supplementary information files].
  • The datasets generated and/or analysed during the current study are not publicly available due [REASON WHY DATA ARE NOT PUBLIC] but are available from the corresponding author on reasonable request.
  • Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
  • The data that support the findings of this study are available from [third party name] but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of [third party name].
  • Not applicable. If your manuscript does not contain any data, please state 'Not applicable' in this section.

More examples of template data availability statements, which include examples of openly available and restricted access datasets, are available here .

BioMed Central strongly encourages the citation of any publicly available data on which the conclusions of the paper rely in the manuscript. Data citations should include a persistent identifier (such as a DOI) and should ideally be included in the reference list. Citations of datasets, when they appear in the reference list, should include the minimum information recommended by DataCite and follow journal style. Dataset identifiers including DOIs should be expressed as full URLs. For example:

Hao Z, AghaKouchak A, Nakhjiri N, Farahmand A. Global integrated drought monitoring and prediction system (GIDMaPS) data sets. figshare. 2014. http://dx.doi.org/10.6084/m9.figshare.853801

With the corresponding text in the Availability of data and materials statement:

The datasets generated during and/or analysed during the current study are available in the [NAME] repository, [PERSISTENT WEB LINK TO DATASETS]. [Reference number]  

If you wish to co-submit a data note describing your data to be published in BMC Research Notes , you can do so by visiting our submission portal . Data notes support open data and help authors to comply with funder policies on data sharing. Co-published data notes will be linked to the research article the data support ( example ).

All financial and non-financial competing interests must be declared in this section.

See our editorial policies for a full explanation of competing interests. If you are unsure whether you or any of your co-authors have a competing interest please contact the editorial office.

Please use the authors initials to refer to each authors' competing interests in this section.

If you do not have any competing interests, please state "The authors declare that they have no competing interests" in this section.

All sources of funding for the research reported should be declared. If the funder has a specific role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript, this should be declared.

The individual contributions of authors to the manuscript should be specified in this section. Guidance and criteria for authorship can be found in our editorial policies .

Please use initials to refer to each author's contribution in this section, for example: "FC analyzed and interpreted the patient data regarding the hematological disease and the transplant. RH performed the histological examination of the kidney, and was a major contributor in writing the manuscript. All authors read and approved the final manuscript."

Please acknowledge anyone who contributed towards the article who does not meet the criteria for authorship including anyone who provided professional writing services or materials.

Authors should obtain permission to acknowledge from all those mentioned in the Acknowledgements section.

See our editorial policies for a full explanation of acknowledgements and authorship criteria.

If you do not have anyone to acknowledge, please write "Not applicable" in this section.

Group authorship (for manuscripts involving a collaboration group): if you would like the names of the individual members of a collaboration Group to be searchable through their individual PubMed records, please ensure that the title of the collaboration Group is included on the title page and in the submission system and also include collaborating author names as the last paragraph of the “Acknowledgements” section. Please add authors in the format First Name, Middle initial(s) (optional), Last Name. You can add institution or country information for each author if you wish, but this should be consistent across all authors.

Please note that individual names may not be present in the PubMed record at the time a published article is initially included in PubMed as it takes PubMed additional time to code this information.

Authors' information

This section is optional.

You may choose to use this section to include any relevant information about the author(s) that may aid the reader's interpretation of the article, and understand the standpoint of the author(s). This may include details about the authors' qualifications, current positions they hold at institutions or societies, or any other relevant background information. Please refer to authors using their initials. Note this section should not be used to describe any competing interests.

Footnotes can be used to give additional information, which may include the citation of a reference included in the reference list. They should not consist solely of a reference citation, and they should never include the bibliographic details of a reference. They should also not contain any figures or tables.

Footnotes to the text are numbered consecutively; those to tables should be indicated by superscript lower-case letters (or asterisks for significance values and other statistical data). Footnotes to the title or the authors of the article are not given reference symbols.

Always use footnotes instead of endnotes.

Examples of the Vancouver reference style are shown below.

See our editorial policies for author guidance on good citation practice

Web links and URLs: All web links and URLs, including links to the authors' own websites, should be given a reference number and included in the reference list rather than within the text of the manuscript. They should be provided in full, including both the title of the site and the URL, as well as the date the site was accessed, in the following format: The Mouse Tumor Biology Database. http://tumor.informatics.jax.org/mtbwi/index.do . Accessed 20 May 2013. If an author or group of authors can clearly be associated with a web link, such as for weblogs, then they should be included in the reference.

Example reference style:

Article within a journal

Smith JJ. The world of science. Am J Sci. 1999;36:234-5.

Article within a journal (no page numbers)

Rohrmann S, Overvad K, Bueno-de-Mesquita HB, Jakobsen MU, Egeberg R, Tjønneland A, et al. Meat consumption and mortality - results from the European Prospective Investigation into Cancer and Nutrition. BMC Medicine. 2013;11:63.

Article within a journal by DOI

Slifka MK, Whitton JL. Clinical implications of dysregulated cytokine production. Dig J Mol Med. 2000; doi:10.1007/s801090000086.

Article within a journal supplement

Frumin AM, Nussbaum J, Esposito M. Functional asplenia: demonstration of splenic activity by bone marrow scan. Blood 1979;59 Suppl 1:26-32.

Book chapter, or an article within a book

Wyllie AH, Kerr JFR, Currie AR. Cell death: the significance of apoptosis. In: Bourne GH, Danielli JF, Jeon KW, editors. International review of cytology. London: Academic; 1980. p. 251-306.

OnlineFirst chapter in a series (without a volume designation but with a DOI)

Saito Y, Hyuga H. Rate equation approaches to amplification of enantiomeric excess and chiral symmetry breaking. Top Curr Chem. 2007. doi:10.1007/128_2006_108.

Complete book, authored

Blenkinsopp A, Paxton P. Symptoms in the pharmacy: a guide to the management of common illness. 3rd ed. Oxford: Blackwell Science; 1998.

Online document

Doe J. Title of subordinate document. In: The dictionary of substances and their effects. Royal Society of Chemistry. 1999. http://www.rsc.org/dose/title of subordinate document. Accessed 15 Jan 1999.

Online database

Healthwise Knowledgebase. US Pharmacopeia, Rockville. 1998. http://www.healthwise.org. Accessed 21 Sept 1998.

Supplementary material/private homepage

Doe J. Title of supplementary material. 2000. http://www.privatehomepage.com. Accessed 22 Feb 2000.

University site

Doe, J: Title of preprint. http://www.uni-heidelberg.de/mydata.html (1999). Accessed 25 Dec 1999.

Doe, J: Trivial HTTP, RFC2169. ftp://ftp.isi.edu/in-notes/rfc2169.txt (1999). Accessed 12 Nov 1999.

Organization site

ISSN International Centre: The ISSN register. http://www.issn.org (2006). Accessed 20 Feb 2007.

Dataset with persistent identifier

Zheng L-Y, Guo X-S, He B, Sun L-J, Peng Y, Dong S-S, et al. Genome data from sweet and grain sorghum (Sorghum bicolor). GigaScience Database. 2011. http://dx.doi.org/10.5524/100012 .

Figures, tables and additional files

See  General formatting guidelines  for information on how to format figures, tables and additional files.

Submit manuscript

  • Editorial Board
  • Manuscript editing services
  • Instructions for Editors
  • Contact Support for Editors
  • Sign up for article alerts and news from this journal
  • Follow us on Twitter
  • Follow us on Facebook

Annual Journal Metrics

2022 Citation Impact 3.4 - 2-year Impact Factor 4.2 - 5-year Impact Factor 1.657 - SNIP (Source Normalized Impact per Paper) 1.093 - SJR (SCImago Journal Rank)

2022 Speed 33 days submission to first editorial decision for all manuscripts (Median) 202 days submission to accept (Median)

2022 Usage  3,068,473 downloads 6,675 Altmetric mentions 

  • More about our metrics

Reproductive Health

ISSN: 1742-4755

IMAGES

  1. Report

    a case report example

  2. Medical Report Sample Doc

    a case report example

  3. How To Write A Medical Case Study Template

    a case report example

  4. How-to-write-a-case-report

    a case report example

  5. (PDF) A case report of case report pursuit by medical student

    a case report example

  6. 😊 How to format a case study paper. How to Make a Case Study Format

    a case report example

VIDEO

  1. How to Create a Case Report in Salesforce [QUICK GUIDE]

  2. Example of Short Report in English

  3. Stock Condition Report

  4. Instead of taking revenge, we have to set an example in politics

  5. Case Reports: Do your RESEARCH!

  6. LEARN😎 TO WRITE✍🏾 CASE REPORT IN 2 MINUTES 😱

COMMENTS

  1. Guidelines To Writing A Clinical Case Report

    A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine.

  2. PDF 10. Guideline and Template for Writing a Case Report/Case Series

    Step 1: state the obvious Start by asking yourself: What are we talking about? Whom are we talking about? Why is this observation important? Who needs to know about this case? Example Tuberculosis - Severely malnourished child - Atypical presentation of the disease - Pediatricians in humanitarian and resource-limited settings

  3. Case Report: A Beginner's Guide with Examples

    Real-world examples of case reports Example 1: Normal plasma cholesterol in an 88-year-old man who eats 25 eggs a day This is the case of an old man with Alzheimer's disease who has been eating 20-30 eggs every day for almost 15 years. [ Source]

  4. Tips for writing a case report for the novice author

    The case report as a source of new knowledge refers to visualization of a new manifestation or finding, or clearer demonstration of a known feature of a disease, using a new imaging technology or an imaging method. 18, 19 Figure 1 is an example showing 3D virtual endoscopy and the unique intraluminal views of the coronary lumen provided by this ...

  5. Writing A Case Report

    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.

  6. Writing a case report in 10 steps

    First steps Begin by sitting down with your medical team to discuss the interesting aspects of the case and the learning points to highlight. Ideally, a registrar or middle grade will mentor you and give you guidance. Another junior doctor or medical student may also be keen to be involved.

  7. Guideline on writing a case report

    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]

  8. How to Write a Case Report

    Create the timeline of your case report—a visual summary of WHAT happened in the case report (see examples of timelines that follow the CARE guidelines) before writing the narrative section. Third : Complete the remainder of the case report using specialty-specific information if necessary with appropriate scientific references and explanations.

  9. Case Report

    Definition An article that describes and interprets an individual case, often written in the form of a detailed story. Case reports often describe: Unique cases that cannot be explained by known diseases or syndromes Cases that show an important variation of a disease or condition

  10. LibGuides: Case Reports: How to Write a Case Report

    This checklist was developed by CARE to correspond with key components of a case report and capture useful clinical information (including 'meaningful use' information mandated by some insurance plans).. The narrative: A case report tells a story in a narrative format that includes the presenting concerns, clinical findings, diagnoses, interventions, outcomes (including adverse events), and ...

  11. Structure of a Case Report

    A case report ends with a conclusion or with summary points, depending on the journal's specified format. This section should briefly give readers the key points covered in the case report. Here, the author can give suggestions and recommendations to clinicians, teachers, or researchers. Some journals do not want a separate section for the ...

  12. How to write a medical case report

    The writing of a case report rests on skills that medical students acquire in their medical training, which they use throughout their postgraduate careers: these include history taking, interpretation of clinical signs and symptoms, interpretation of laboratory and imaging results, researching disease aetiology, reviewing medical evidence, and w...

  13. PDF Writing and publishing a useful and interesting Case Report

    Title of case. You do not need to include "a case report" in the title - you may be cryptic if you wish. Summary. This will be freely available online. Up to 150 words summarising the case presentation and outcome. We need a good flavour of the case - emphasise the learning points. Background.

  14. PDF How to write a clinical case report

    It is best to write the actual report in one stretch if possible, including as much detail as you think is relevant. You can always edit the discussion and trim down the article at a later stage. Below is the general format adopted for most case reports. Introduction. Summarise your case report in a sentence. Mention how rare this condition is ...

  15. Case report

    Criteria. Journal of Medical Case Reports welcomes well-described reports of cases that include the following: Unreported or unusual side effects or adverse interactions involving medications. Unexpected or unusual presentations of a disease. New associations or variations in disease processes. Presentations, diagnoses and/or management of new ...

  16. How to review a case report

    The definition of a case report or a case series is not well defined in the literature and has been defined variously by different journals and authors. However, the basic definition of a case report is the detailed report of an individual including aspects like exposure, symptoms, signs, intervention, and outcome. ... For example, if a case is ...

  17. How to write a case report Which journal to choose

    information about the case. It is also useful to have a copy of any case report from a previous issue of the journal to get an idea of the pres-entation. It is extremely important to understand the basic format required by the journal. Your case report may be rejected because it does not conform to the standard format, no matter how good the ...

  18. A guide to writing case reports for the Journal of Medical Case Reports

    Examples abound. Few practicing physicians would not know for instance the significance and subsequent discovery of a disease whose first description in 1981 began with the title in the medical case report literature as: "A preliminary communication on extensively disseminated Kaposi's sarcoma in a young homosexual man" [ 4 ].

  19. Writing a Clinical Vignette (Case Report) Abstract

    Case reports represent the oldest and most familiar form of medical communication. Far from a "second-class" publication, many original observations are first presented as case reports. Like scientific abstracts, the case report abstract is governed by rules that dictate its format and length. This article will outline the features of a well-written case report abstract and provide an example ...

  20. How to write a case report

    Rahij Anwar and colleagues give advice on the practical details of writing case reports Research has become an integral part of medical careers. A case report is a way of communicating information to the medical world about a rare or unreported feature, condition, complication, or intervention by publishing it in a medical journal. Be on the look out for a case report from the start of your ...

  21. Investigation Report Example: How to Write an Investigative ...

    Date of the interview. Summary of the substance of the interview, based on your interview notes or recording. Example: I asked Jane Jameson to describe the events of July 13th, 2016. She said: "After work, Peter approached me as I was leaving the building and asked me if I would like to work on his team.

  22. Case Report of Acute Elder Patients in Intensive Care Unit ...

    The older patient in the case report had a good outcome. There are many reasons behind this positive outcome. First, the patient had a CFS grade of 3 before the hospital admission and had a potentially reversible acute disease. She stayed in the ICU for a few days and then in geriatric intensive care. The important question is whether this ...

  23. Case Report Form: Types Uses & Template Examples

    The data gathered via case report forms (CRFs) are analyzed to arrive at the research results and draw valid conclusions. It is one of the most effective ways to systematically collect and store all the information from research for use. For example, during clinical trials to test the efficacy of a drug, you need to collect data at every stage ...

  24. How to Write a Case Report?

    The use of propranolol for the management of infantile hemangiomas is an example; which came into limelight with the publication of case reports; and thereafter, large-scale experimental studies were designed. [ 5, 6, 7] Therefore, case reports aid in designing tenable protocol for performing good quality scientific research. [ 8]

  25. The Civil Fraud Ruling on Donald Trump, Annotated

    Former President Donald J. Trump was penalized $355 million plus interest and banned for three years from serving in any top roles at a New York company, including his own, in a ruling on Friday ...

  26. Accomplishment Report for Remedial Classes

    This report aims to highlight the significant progress and achievements made in the remedial classes conducted at Springfield Community School during the academic year 2023-2024. Designed to support students who required additional help in English and Mathematics, the remedial program has successfully enhanced student understanding and academic ...

  27. Case report

    Case report submissions will be assessed by the Editors and will be sent for peer review if considered appropriate for the journal. Authors should seek written and signed consent to publish the information from the patients or their guardians prior to submission. ... More examples of template data availability statements, which include examples ...