Case reports are an important way to illustrate new and rare conditions, diseases and treatments.
Case reports allow medical and psychiatric professionals to share their experiences and research with other physicians on distinctive or rare conditions, diseases and treatments through publishing their findings in a professional journal. While case reports are some of the simplest of journal submissions to write, the basic format for case reports includes five sections: introduction, case description, discussion, conclusion and references.
The Introduction
The introduction should be a brief description of the case topic. Any exceptional circumstances or rarities should be clearly addressed. The American College of Physicians notes that while the introduction is important, it is also acceptable to exclude it and begin the case report with the case description.
The Case Description
The case description is the section of the report that includes all relevant information collected in the research. This includes patient history, exam reports, laboratory results, conclusion and progress notes. Permission to include this information should be obtained from the patient prior to the beginning of the writing process. In addition, if the patient is under the care of a third-party physician, the physician should be consulted as a professional courtesy. While physicians should be thorough in their case descriptions, it is important "to be complete without obscuring the essence of the case with irrelevant details," states the American College of Physicians.
The Discussion
The purpose of the third section is to evaluate the choices made in treatment and diagnosis. In addition, the discussion provides an opportunity for the author to review other relevant literature on the topic either to support the conclusions or to illustrate other views on the subject. Based upon the information presented, the physician can then make a recommendation, extract a lesson or make an argument concerning the particular condition.
The Conclusion
A conclusion, like an introduction, is not a necessity in a case report. However, when a conclusion is used it allows the writer to summarize the case and findings. This section should be brief and include any additional recommendations, or new directions in study and research, that have come to light as a result of the case report.
References
A properly formatted list of references is the final, and necessary, step in the writing process. All references must be properly documented and listed on a reference page formatted in the style required by the journal to which the report will be submitted. Each reference should be numbered using Arabic numerals such as 1, 2, 3, etc.
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