Writing Case Reports

Guidelines for writing “Case Reports” for the South Sudan Medical Journal

Learning from, and sharing of, experiences are valuable exercises for all healthcare professionals. This is especially, but not exclusively, the case for unusual clinical presentations.

A “Case Report” should be written clearly, contain all necessary information for the reader to make a judgement and highlight specific “Learning Points”. It should tell a clear story from presentation to discharge or death with all decisions explained. Descriptions of complications are especially useful. Wherever possible obtain permission from the patient and hospital / medical authorities. If the patient has died ask a relative. Make sure the patient cannot be recognised from the details you give; if you want to use a image you must first obtain permission from the patient or relative. A sample consent form is given below.

It is useful to have a generally agreed structure for “Case Reports” and the following is recommended:

“Case Report”

1. Introduction

This should be brief, set the scene for the case to be reported and why the case is of interest. Reference to important literature may be included.

2. Clinical assessment

History and Examination

This should include all relevant information including the negative findings. State the exact facts and avoid the use of the word “normal”. Avoid abbreviations. 

3. Investigations

Again quote the exact data rather than the expression “normal”. In certain circumstances it may be necessary to indicate the “normal” ranges accepted in the laboratory that carried out the tests. State if an investigation was considered but facilities were unavailable.

4. Differential diagnosis

Discussing this briefly is part of the “problem-solving” exercise that we should always undertake. It will indicate to the reader that the clinician has thought through the problem and considered the most appropriate investigations.

5. Treatment and Progress

Treatment should be based upon the above and the selection of treatment schedules should be shown to be logical: although always they will be determined by local circumstances and availability.

Describe the progress of the patient and any supportive clinical measurements (e.g. pulse rate, blood pressure, temperature, urine output, body weight, Glasgow Coma Scale) and laboratory investigations. Where multiple measurements have been made over time a simple table or graph can be very informative.

6. Comment

This gives the writer the opportunity to highlight any “Learning Points” and refer to appropriate literature. Brief descriptions of diagnostic pathways and treatment guidelines (aided with simple diagrams) may also be helpful. In addition this section should encourage readers to send their comments to the “SSMJ” and report their experiences. In this way the collective learning process is enhanced.

7. References

Under this section the references noted are to support statements made in the “Introduction” and “Comment”.

Suggested Consent Form:

Consent Form

Name of person described in the article and / or shown in the photograph:

...........................................................

Subject matter of the article and / or photograph:

...........................................................

Journal name: South Sudan Medical Journal

Title of article: ............................................................................

Names of authors: .......................................................................

I ................................................... (insert full name) give my consent for this information about myself / my child / my relative (circle the one that applies) relating to the above article / photograph(s) (circle which applies) to appear in the named journal.

I understand:

  1. The information will be published without my name being stated and every effort will be made to ensure my anonymity although this cannot always be guaranteed.
  2. The journal goes to doctors and other healthcare professionals. It may also be seen by others e.g. journalists.
  3. The information will appear on the journal’s web site: http://www.southsudanmedicaljournal.com
  4. The information will not be allowed to be used for advertising, packaging or out of context.
  5. I can reverse my consent at any time BEFORE publication.

Signed.........................................

patient in the article / parent of patient / relative of patient (circle which applies)

Date: ...........................................