careers

Writing a medical case report

Case reports have fallen out of favour, but they still have a role to play

Box 1: Famous case reports

Multiple myeloma Henry Bence-Jones (left) and William MacIntyre contributed greatly to our understanding of multiple myeloma by recording the effect of this disease on Thomas Alexander McBean. They found that Mr McBeans urine was abound in animal matter. It is owing to this observation that the protein found in urine of patients with multiple myeloma is called Bence-Jones protein. Mental health disorders Sigmund Freud, best known for his psychoanalysis and theories of the unconscious mind, also had a special interest in recording the case histories of his patients. Many of his case reports helped further our understanding of a number of mental health disorders, such as obsessive compulsive disorder (rat man), dissociative disorder (Anna O), phobias (Little Hans) and post-traumatic disorder (wolf man). Dysphasia Brocas area, the speech production centre in the brain, was named after Paul Pierre Broca, a French physician and anatomist. He made his discovery while studying the brains of dysphasic patients. The first patient that he examined was nicknamed Tan because of his inability to say any word apart from Tan, which he repeated over and over. On postmortem examination Broca discovered that Tan had a fluid filled cavity in the left hemisphere caused by syphilis and concluded that this area is responsible for speech production in humans.

Given the unpredictable and challenging nature of medicine, many medical students will have come across a patient who has not been a textbook case. The patient may have presented in an unusual way, had a strange new pathology, or reacted to a medical intervention in a manner that has not been seen before. The publication of these novelties and curiosities as case reports has for many centuries been a fundamental way of sharing knowledge and conveying medical experience, and throughout history there have been famous case studies that have helped shape the way we view health and disease (box ). There are those who argue, however, that case reports are increasingly irrelevant in current medical practice and education. Their obscurity and rarity appeal only to the specialised few, and they add little to everyday medical practice. Their anecdotal nature lacks the scientic rigour of large, well conducted studies, and they have therefore fallen down the hierarchical ladder of medical evidence (box ). Sadly, many medical journals now refuse to publish case reports. Despite their limitations, case reports still have a role to play in furthering medical knowledge and education. Their ability to ag up novelty means that they are still used to identify emerging pathologies. Case reports also hold valuable educational worth as brief clinical caveats. Many people nd abstract medical knowledge easier to remember when linked to a patient. Di erent areas of medical education such as physiology, pathology, pharmacology, and anatomy are brought together in case reports and help students and doctors to develop a more holistic approach to patients. Should I try and write a case report? Case reports help students gain a deeper understanding of a medical topic, but they also act as an excellent introduction to academic writing. Doing a literature review, structuring a manuscript, and learning how to submit and revise your article are skills worth developing early on. In addition to this, a published case report is a contribution (though small) to medical science and a way to get your name in print; it is also something that can be put on your curriculum vitae and help you stand out in future job applications. How do I go about nding a suitable case to report? As a medical student it is di cult to know when a case is unique or interesting enough to warrant reporting, and it is therefore important to make the most of help from your seniors. If youre in a clinic or on the ward and you hear a consultant mention that a case is rare, or that theyve never seen one like it before, its worth inquiring whether you could write it up as a case report. If you dont have the good fortune of coming across any suitable cases it is also worth asking if any of the senior doctors have cases that you could help them research and write up.
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Box 2: Evidence needed5

Category IEvidence from at least one properly randomised controlled trial Category II- Evidence from well designed controlled trials without randomisation Category II- Evidence from well designed cohort or case-control analytic studies, preferably from more than one centre or research group Category II- Evidence from multiple case series with or without intervention or dramatic results in uncontrolled experiments Category IIIOpinions of respected authorities, based on clinical experience, descriptive studies, and case reports, or reports of expert committees.
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Preparation When you have found a suitable case it is vital to do a number of tasks before you can start putting pen to paper. Literature review A literature review on a medical database such as PubMed, Ovid, or Medline can be used to check if there have been any similar cases; this helps you gauge how rare your case is. Liaising with doctors in charge It is very important to discuss writing a case report with the senior clinician in charge of the patients care. Not only must you gain their permission, but they will also help to provide guidance and advice. In addition, it is also worth discussing the case with clinicians of other specialties (such as pathology, radiology, and microbiology) who have played a role in the patients care. Gaining consent Check the journal guidelines carefully. It is extremely important to gain written consent from the patient if you wish to include pictures or clinical details from which they may be identified. During the consent process you must explain why you wish to share their case with others, the risks and benefits of doing so, and you must answer any questions they may have. Get senior help for this. Data collection When you have done your literature review, liaised with the senior doctor, and gained consent from the patient you can start bringing your patients case together. This involves finding his or her medical notes, laboratory results, imaging, and any other relevant material. How do I structure a medical case report? The basic structure of a medical case report is as follows: AbstractThis section is read by people trying to decide whether they wish to go on and read your full case report. It is therefore vital to keep it concise (no more than 150 words) and snappy, and to encompass all the important aspects of your case, particularly highlighting what this adds to medical knowledge. Case reportIn this section you are presenting your patient to the reader. This should include a concise history and any relevant examination and investigation findings. It is important to include any relevant negatives based upon the potential diagnoses, but do not clutter this section with unnecessary detail. DiscussionWhen you have presented your case to the reader you are expected to put it into context in the discussion section. Here you give information about the condition or intervention in question, such as the basic epidemiology, pathophysiology, clinical presentation, investigations, and treatment. As you paint this picture it is extremely important for you to show how your case has differed from the norm and how this is contributing to medical understanding. Where can I get my case reports published? Given the reluctance of many journals to publish case reports these days, where are you to turn when you wish to share your newly written up experience of an interesting case? Fortunately, the vastness of cyberspace has allowed for the development of a new breed of medical journal. A number of new online journals such as BMJ Case Reports (www.casereports. bmj.com), Cases Journal (www.casesjournal.com), the Journal of Medical Case Reports (www.jmedicalcasereports.com), Radiology Case Reports (www.radiology.casereports.net/index.php/rcr), and the Journal of Dermatological Case Reports (www.jdcr.eu) allow the publication and dissemination of notable case reports. These
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If you are writing up a patients case, attending the case review meeting will be useful

allow doctors from all over the world to share their experiences of new and interesting cases. Although still in their infancy, these journals have the potential to act as large case banks that allow doctors to search for cases similar to ones that may be puzzling them, to help guide their management.
Further reading
Anwar R, Kabir H, Botchu R, Khan SA, Gogi N. How to write a case report. studentBMJ 2004;12:45-88.
Aimun A B Jamjoom foundation year 1 doctor, Lincoln County Hospital, Lincoln LN2 5QY, aabjamjoom@googlemail.com Ali Nikkar-Esfahani final year medical student, University of Nottingham Medical School, Queens Medical Centre, Nottingham NG7 2UH J E F Fitzgerald specialty trainee, general surgery, Medical Education Unit, University of Nottingham Medical School Competing interests: None declared. Provenance and peer review: Not commissioned; externally peer reviewed.
1 2 3 4 5 Yadav H. The philosophy of the medical case. studentBMJ 2006;14:133-76. Kyle RA. Multiple myeloma: an odyssey of discovery. Br J Haematol 2000;111:1035-44. Heller S. Freud A to Z. Wiley, 2005. Schiller F. Paul Broca: founder of French anthropology, explorer of the brain. Oxford University Press, 1992. Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, et al. Current methods of the US preventive services task force: a review of the process. Am J Prev Med 2001;20:21-35.

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