How to Prepare a Case Report

In the past couple of weeks I have had an opportunity to work with several faculty members who were interested in preparing case reports. It was my honor to do so. It led me to consider offering up a few thoughts on how to get them ready for publication.

The easiest way to prep a case report involves, really, just two issues: one is to have the case records at hand, and the second is to know the general template for putting that information into readable from. Assuming that you have the records available, I will focus on the second item here.

The general format or template for a case reports is: Structured Abstract, Introduction, Case Report, Discussion, Conclusion, References.

Structured Abstract: Really, this should be prepared last, after the paper is completed. But when you are ready, most journals require a structured abstract with specific subheadings: Objective (why are you writing the paper?); Clinical Features (what were the features the patient had when he or she came for care, leading you to your diagnosis?); Intervention and Outcome (what did you do and how did the patient respond?); Conclusion (what do you conclude for the above?). And you have to do all of this in 250 words or less.

Introduction: This usually will provide some background information on the condition of interest, as well as provide some context for the educational value of the case. Put it this way: what is unusual here, what gap in the literature will be filled by publishing the case?

Case Report: Well, this is the report of the case, of course. It needs to provide the reader only the essential information: on diagnosis and tests run, on treatment and on outcome. The reader should be able to confirm that you made a correct diagnosis, and they should be able to understand the intricacies of your treatment, and they should be able to assess the outcome instruments you used for monitoring progress.

Discussion: This explains the educational value of the paper. What did we learn here? How does what we learned here fit into the larger body of information available about this condition or topic? The primary function of a case report is to educate the reader, to help them learn something. That should be the focus of the paper- so, you may focus on teaching about the condition, or perhaps its management or perhaps something else.

Conclusion: This is really just a recapitulation of what came before. It should not offer any speculation, but may suggest directions for future research based on what you found.

References: Of course, references are important since they provide the foundation for the importance of your case.

I recommend that you pick up a case report or two from a chiropractic journal and look to see how well they fit into this template. Knowing these components can ease the fear you might feel in considering writing something for publication.

As I prepared to post this, I received a note from Dr. Karen Boulanger, about a new paper she co-wrote related to preparing case reports. It is excellent and can be accessed at http://ijtmb.org/index.php/ijtmb/article/view/251/303