1. Charts/Graphs/Pictures Significance/Background
Title:
Authors:
Introduction
Patient Description
Charts/Graphs/Pictures
Discussion
Describe the patient including gender, age, height weight, BMI, social history (including tobacco and alcohol use), use of illegal substances, medication being used, notable results of physical examination and laboratory tests, and differential diagnosis or diagnoses considered, just to name a few. When in doubt, think about the patient information you would like to know as background information and provide it in this section. Don’t go overboard; we don’t need to know how many toilets are in the patient’s primary residence. Give all of the basics and add the specifics important to the case.
Remember: When writing up your case report, refrain from using any identifying data, such as date of birth, date of service, patient name, initials or medical record number. Do not use case when referring to a person - a case is an instance of disease, a patient is a person.
The purpose of the discussion is to explain anything that isn't clear in the case description and to offer interpretations of findings. It’s also the spot to indicate why the intervention used for your case was different from similar cases reported previously. Make clear any important point that isn't explained in the case descriptions. For example, if you reported that liver enzymes were elevated but no significant liver dysfunction was found, tell the reader in the discussion section why the enzymes were elevated. Also discuss implications for the field.
The introduction should be brief; tell why the case is important and why it is being reported (i.e., because it adds to the understanding of a clinical problem). For the sake of brevity, cite a few recent review articles rather than many individual studies. Case reports usually respond to one of the following generic topics, but use specific information from the case being presented.
An unexpected association between diseases or symptoms. (For example, AIDS came to be recognized, in part, because Kaposi's sarcoma and Pneumocystis carinii pneumonia were reported in homosexual men in 1981.)
An unexpected event in the course of observing or treating a patient. (The transdermal absorption of nitroglycerin and its dilating effect on blood vessels came to be understood after a physician reported headache in a patient who handled TNT powder in his daily work.)
Findings that shed new light on the possible pathogenesis of a disease or an adverse effect.
Unique or rare features of a disease.
Unique therapeutic approaches.
For most of your audience, this section will hold the most interest and will also be the biggest attention-grabber for the casual passer-by. They may not care for your title of “A Rare Case of Okra Toxicity in Bexar County” but the full color 3D CT of a tortured liver will suck them right in.
Remember: Pictures which contain patient identifiers (e.g., facial shots, unusual tattoos) will require a signed release form from the patient. Check with the MH Research Department for more information.
Response to Treatment
Describe the outcome of treatment including final diagnosis.
Intervention
Describe all therapeutic interventions conducted during the course of treatment. Only provide the results of relevant examinations and laboratory tests (usually those with positive results).
List the laboratory's ranges of normal values for any unusual tests performed.
Significance/Background
Using the literature, establish any previous work related to your research question. This section should describe the gap(s) in the literature, and how your specific aims will attempt to address the gap.
References
While it is a nice thing to include references, if you’re crunched for space, these are the first things to go. If the choice is between including a really good looking graph or the references, ditch the references and show the graph.