The Parts of a Medical Case Report

The American College of Physicians reports:

"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...Scientific forums have specific rules regarding how the abstract should appear...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...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...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 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, [or] 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...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...[F]ollow 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...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...[A]void 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...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."