how to write up a patient case study

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Guidelines To Writing A Clinical Case Report

What is a clinical case report.

A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine. Some reports contain an extensive review of the relevant literature on the topic. The case report is a rapid short communication between busy clinicians who may not have time or resources to conduct large scale research.

WHAT ARE THE REASONS FOR PUBLISHING A CASE REPORT?

The most common reasons for publishing a case are the following: 1) an unexpected association between diseases or symptoms; 2) an unexpected event in the course observing or treating a patient; 3) findings that shed new light on the possible pathogenesis of a disease or an adverse effect; 4) unique or rare features of a disease; 5) unique therapeutic approaches; variation of anatomical structures.

Most journals publish case reports that deal with one or more of the following:

• Unusual observations
• Adverse response to therapies
• Unusual combination of conditions leading to confusion
• Illustration of a new theory
• Question regarding a current theory
• Personal impact.

STRUCTURE OF A CASE REPORT[ 1 , 2 ]

Different journals have slightly different formats for case reports. It is always a good idea to read some of the target jiurnals case reports to get a general idea of the sequence and format.

In general, all case reports include the following components: an abstract, an introduction, a case, and a discussion. Some journals might require literature review.

The abstract should summarize the case, the problem it addresses, and the message it conveys. Abstracts of case studies are usually very short, preferably not more than 150 words.

Introduction

The introduction gives a brief overview of the problem that the case addresses, citing relevant literature where necessary. The introduction generally ends with a single sentence describing the patient and the basic condition that he or she is suffering from.

This section provides the details of the case in the following order:

• Patient description
• Case history
• Physical examination results
• Results of pathological tests and other investigations
• Treatment plan
• Expected outcome of the treatment plan
• Actual outcome.

The author should ensure that all the relevant details are included and unnecessary ones excluded.

This is the most important part of the case report; the part that will convince the journal that the case is publication worthy. This section should start by expanding on what has been said in the introduction, focusing on why the case is noteworthy and the problem that it addresses.

This is followed by a summary of the existing literature on the topic. (If the journal specifies a separate section on literature review, it should be added before the Discussion). This part describes the existing theories and research findings on the key issue in the patient's condition. The review should narrow down to the source of confusion or the main challenge in the case.

Finally, the case report should be connected to the existing literature, mentioning the message that the case conveys. The author should explain whether this corroborates with or detracts from current beliefs about the problem and how this evidence can add value to future clinical practice.

A case report ends with a conclusion or with summary points, depending on the journal's specified format. This section should briefly give readers the key points covered in the case report. Here, the author can give suggestions and recommendations to clinicians, teachers, or researchers. Some journals do not want a separate section for the conclusion: it can then be the concluding paragraph of the Discussion section.

Notes on patient consent

Informed consent in an ethical requirement for most studies involving humans, so before you start writing your case report, take a written consent from the patient as all journals require that you provide it at the time of manuscript submission. In case the patient is a minor, parental consent is required. For adults who are unable to consent to investigation or treatment, consent of closest family members is required.

Patient anonymity is also an important requirement. Remember not to disclose any information that might reveal the identity of the patient. You need to be particularly careful with pictures, and ensure that pictures of the affected area do not reveal the identity of the patient.

Writing a Case Report

This page is intended for medical students, residents or others who do not have much experience with case reports, but are planning on writing one.  

What is a case report?  A medical case report, also known as a case study, is a detailed description of a clinical encounter with a patient.  The most important aspect of a case report, i.e. the reason you would go to the trouble of writing one, is that the case is sufficiently unique, rare or interesting such that other medical professionals will learn something from it.   

Case reports are commonly of the following categories :

- Rare diseases

- Unusual presentation of disease

- Unexpected events

- Unusual combination of diseases or conditions

- Difficult or inconclusive diagnosis

- Treatment or management challenges

- Personal impact

- Observations that shed new light on a disease or condition

- Anatomical variations

It is important that you recognize what is unique or interesting about your case, and this must be described clearly in the case report.

Case reports generally take the format of :

1. Background

2. Case presentation

3. Observations and investigation

4. Diagnosis

5. Treatment

7. Discussion

Does a case report require IRB approval?

Case reports typically discuss a single patient. If this is true for your case report, then it most likely does not require IRB approval because it not considered research.    If you have more than one patient, your study could qualify as a Case Series, which would require IRB review.  If you have questions, you chould check your local IRB's guidelines on reviewing case reports.

Are there other rules for writing a case report?

First, you will be collecting protected health information, thus HIPAA applies to case reports.   Spectrum Health has created a very helpful guidance document for case reports, which you can see here:   Case Report Guidance - Spectrum Health

While this guidance document was created by Spectrum Health, the rules and regulations outlined could apply to any case report.  This includes answering questions like: Do I need written HIPAA authorization to publish a case report?  When do I need IRB review of a case report?  What qualifies as a patient identifier?

How do I get started?

1. We STRONGLY encourage you to consult the CARE Guidelines, which provide guidance on writing case reports -  https://www.care-statement.org/

Specifically, the checklist -  https://www.care-statement.org/checklist  - which explains exactly the information you should collect and include in your case report.  

2. Identify a case.  If you are a medical student, you may not yet have the clinical expertise to determine if a specific case is worth writing up.  If so, you must seek the help of a clinician.  It is common for students to ask attendings or residents if they have any interesting cases that can be used for a case report. 

3. Select a journal or two to which you think you will submit the case report.   Journals often have specific requirements for publishing case reports, which could include a requirement for informed consent, a letter or statement from the IRB and other things.  Journals may also charge publication fees (see Is it free to publish? below)   

4. Obtain informed consent from the patient (see " Do I have to obtain informed consent from the patient? " below).  Journals may have their own informed consent form that they would like you to use, so please look for this when selecting a journal.

Once you've identified the case, selected an appropriate journal(s), and considered informed consent, you can collect the required information to write the case report.

How do I write a case report?

Once you identify a case and have learned what information to include in the case report, try to find a previously published case report.  Finding published case reports in a similar field will provide examples to guide you through the process of writing a case report.    

One journal you can consult is BMJ Case Reports .  MSU has an institutional fellowship with BMJ Case Reports which allows MSU faculty, staff and students to publish in this journal for free.  See this page for a link to the journal and more information on publishing-    https://lib.msu.edu/medicalwriting_publishing/

There are numerous other journals where you can find published case reports to help guide you in your writing. 

Do I have to obtain informed consent from the patient?

The CARE guidelines recommend obtaining informed consent from patients for all case reports.  Our recommendation is to obtain informed consent from the patient.  Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports before publishing.  The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible).  Please consider this as well.  

If required, it is recommended you obtain informed consent before the case report is written.

An example of a case report consent form can be found on the BMJ Case Reports website, which you can access via the MSU library page -  https://casereports.bmj.com/ .  Go to "Instructions for Authors" and then "Patient Consent" to find the consent form they use.  You can create a similar form to obtain consent from your patient.  If you have identified a journal already, please consult their requirements and determine if they have a specific consent form they would like you to use.

Seek feedback

Once you have written a draft of the case report, you should seek feedback on your writing, from experts in the field if possible, or from those who have written case reports before.   

Selecting a journal

Aside from BMJ Case Reports mentioned above, there are many, many journals out there who publish medical case reports.   Ask your mentor if they have a journal they would like to use.  If you need to select on your own, here are some strategies:

1. Do a PubMed search.  https://pubmed.ncbi.nlm.nih.gov/

   a. Do a search for a topic, disease or other feature of your case report 

   b. When the results appear, on the left side of the page is a limiter for "article type".  Case reports are an article type to which you can limit your search results.  If you don't see that option on the left, click "additional filters". 

   c. Review the case reports that come up and see what journals they are published in.

2. Use JANE -  https://jane.biosemantics.org/

3. Check with specialty societies.  Many specialty societies are affiliated with one or more journal, which can be reviewed for ones that match your needs

4. Search through individual publisher journal lists.  Elsevier publishes many different medical research journals, and they have a journal finder, much like JANE  ( https://journalfinder.elsevier.com/ ).  This is exclusive to Elsevier journals.  There are many other publishers of medical journals for review, including Springer, Dove Press, BMJ, BMC, Wiley, Sage, Nature and many others.

Is it free to publish ?

Be aware that it may not be free to publish your case report.  Many journals charge publication fees. Of note, many open access journals charge author fees of thousands of dollars.  Other journals have smaller page charges (i.e. $60 per page), and still others will publish for free, with an "open access option".  It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish.  MSU-CHM does NOT have funds to support publication costs, so this is an important step if you do not want to pay out of pocket for publishing

*A more thorough discussion on finding a journal, publication costs, predatory journals and other publication-related issues can be found here:   https://research.chm.msu.edu/students-residents/finding-a-journal

Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. 2013. The CARE guidelines: Consensus-based clinical case reporting guideline development.  Glob Adv Health Med . 2:38-43. doi:  10.7453/gahmj.2013.008

Riley DS, Barber MS, Kienle GS, AronsonJK, von Schoen-Angerer T, Tugwell P, Kiene H, Helfand M, Altman DG, Sox H, Werthmann PG, Moher D, Rison RA, Shamseer L, Koch CA, Sun GH, Hanaway P, Sudak NL, Kaszkin-Bettag M, Carpenter JE, Gagnier JJ. 2017.  CARE guidelines for case reports: explanation and elaboration document . J Clin Epidemiol . 89:218-234. doi: 10.1016/j.jclinepi.2017.04.026 

Guidelines to writing a clinical case report. 2017. Heart Views . 18:104-105. doi:  10.4103/1995-705X.217857

Ortega-Loubon C, Culquichicon C, Correa R. The importance of writing and publishing case reports during medical education. 2017. Cureus. 9:e1964. doi:  10.7759/cureus.1964

Writing and publishing a useful and interesting case report. 2019. BMJ Case Reports.  https://casereports.bmj.com/pages/wp-content/uploads/sites/69/2019/04/How-to-write-a-Case-Report-DIGITAL.pdf

Camm CF. Writing an excellent case report: EHJ Case Reports , Case of the Year 2019. 2020. European Heart Jounrnal. 41:1230-1231.  https://doi.org/10.1093/eurheartj/ehaa176  

*content developed by Mark Trottier, PhD

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Article Contents

Format of the patient case report, appendix a—criteria for publishable case reports, appendix b—guidelines for writing patient case report manuscripts.

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How to write a patient case report

• Article contents
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Henry Cohen, How to write a patient case report, American Journal of Health-System Pharmacy , Volume 63, Issue 19, 1 October 2006, Pages 1888–1892, https://doi.org/10.2146/ajhp060182

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Purpose. Guidelines for writing patient case reports, with a focus on medication-related reports, are provided.

Summary. The format of a patient case report encompasses the following five sections: an abstract, an introduction and objective that contain a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion. The abstract of a patient case report should succinctly include the four sections of the main text of the report. The introduction section should provide the subject, purpose, and merit of the case report. It must explain why the case report is novel or merits review, and it should include a comprehensive literature review that corroborates the author’s claims. The case presentation section should describe the case in chronological order and in enough detail for the reader to establish his or her own conclusions about the case’s validity. The discussion section is the most important section of the case report. It ought to evaluate the patient case for accuracy, validity, and uniqueness; compare and contrast the case report with the published literature; derive new knowledge; summarize the essential features of the report; and draw recommendations. The conclusion section should be brief and provide a conclusion with evidence-based recommendations and applicability to practice.

Conclusion. Patient case reports are valuable resources of new and unusual information that may lead to vital research.

Published patient case reports provide essential sources of information for the optimum care of patients because case reports can describe important scientific observations that are missed or are undetectable in clinical trials, provide insightful information that expands our knowledge and spawns new research, and provide information that strays from the classical textbook case and leads to better and safer patient care. Indeed, a case report of Kaposi’s sarcoma in a young homosexual man is the seminal observation to the development of acquired immune deficiency syndrome. 1 Seminal patient case reports linked the Food and Drug Administration-approved indication for the anorexic agents, fenfluramine and dexfenfluramine, with primary pulmonary hypertension and subsequently spawned trials that evaluated the mechanism, incidence, and risk factors of this adverse effect, culminating in their withdrawal from the market. 2 , – 5

Many biomedical journals publish case reports and provide authors with guidelines that provide instruction for acceptance criteria, content, and format. The types of relevant patient case reports that merit publication are listed in Appendix A. This article will provide guidelines for writing patient case reports, with a focus on medication-related reports.

Case reports should encompass the following five sections: an abstract, an introduction and objective with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, a summary of the case, and a conclusion. 6 , 7 Supplementary parts such as tables, figures, graphs, and illustrations provide essential data and will enhance the article’s flow and clarity. Generally, most of the data contained in supplementary parts should not be duplicated in the text. 6 , 7 Patient case reports can describe a single case report or a series of case reports. Case reports are generally 1500–2500 words in length with 20–30 references. The title of the case report should be descriptive, accurate, and succinct.

Case reports should include an abstract of 100–250 words. The availability of an abstract will allow for easier retrieval from electronic databases and help researchers discern their levels of interest in the case report. The abstract should include the same four sections as the main text in a succinct form—introduction and objective, case presentation, discussion, and conclusion—but the format may vary depending on a journal’s style if submitted for publication.

Introduction

The introduction section should be concise and salient and immediately attract the attention and interest of the reader. The introduction should provide the subject, purpose, and merit of the case report. It should present background information that provides clarity to the subject of discussion. This should be followed by an explanation of why the case report is novel or merits review. A focused comprehensive literature review that corroborates the author’s claims should accompany the introduction. If few citations are found, they should all be cited chronologically; however, if many citations are found, the seminal, historical, and most pertinent references should be cited. The significant details from the literature review and how those details compare and contrast to the current case should be explained in the discussion, not in the introduction. A brief one-or two-sentence description of the patient case should be provided and is an excellent segue for the case presentation section. The introduction should not be more than three paragraphs and does not need to be labeled with a heading (i.e., Introduction).

A literature review should list the strategy and extent of the search and should include the database searched, the dates that the database was searched, the languages covered, and the search terms used. The literature search should provide enough detail for the reader to easily reproduce the search. Databases that are commonly searched because of their comprehensiveness of biomedical content include MEDLINE and EMBASE. However, it is important that the breadth of the search uses databases that contain information that may not be found in MEDLINE or EMBASE. For example, a case report of an adverse drug event or medication error should include a review of an adverse reaction database such as Clin-Alert or databases that review pharmacy publications such as International Pharmaceutical Abstracts and Iowa Drug Information Service. A case report describing the collaboration of a pharmacist and a nurse that improves a patient’s care should include a search in the nursing database such as the Cumulative Index to Nursing and Allied Health Literature. Furthermore, to maximize the literature search findings, authors should meticulously search the reference lists of review articles and meta-analyses. Finally, clinicians ought to be cognizant that early reports may not be detected in a literature search because of changes in concepts, nomenclature, and terminology since their publication date.

Case presentation

The description of the patient case is one of the most integral sections of the case report. It should describe the case in chronological order and in enough detail for the reader to establish his or her own conclusions about the case’s validity. A case report that contains detailed and relevant patient information allows the reader with a different clinical expertise to uncover idiosyncracies that are not detected or described by the author and stimulates further inquiry and commentary. The case presentation should only include information that pertains to the case and refrain from providing confusing and superfluous data. Daily patient progress including normal vital signs, routine laboratory results, typical consultation with other disciplines, step-down transfers to wards, and other irrelevant patient information must be avoided. The author should establish a causal and temporal relationship and indicate the effect of treatment, any unanticipated effects, the patient’s final outcome, any further proposed treatments, and the patient’s present status at the time of the report.

Patient’s demographics and history

Patient demographics such as age, height, weight, sex, race, and occupation must be included. Although the race or occupation of the patient may appear as superfluous, this type of information may uncover pharmacogenomic or environmental influences. In order to limit the possibility of identifying the patient, the patient’s initials, date of birth, and other identifiers must not be used. Precise dates, including the month, day, and year of admission or other important events, should be avoided—they can aid in identifying the patient and detract the reader from the case report by calculating elapsed time. In a brief summary and in a narrative form, the patient’s chief complaint, present illness, medical history, family and social history, and use of recreational drugs should be listed. Headings for each part of the patient’s history should not be used. The type of physical examination performed should be described, and any abnormalities should be reported.

Patient’s laboratory and diagnostic data

The patient’s laboratory values and diagnostic data that support the case report and rule out a differential diagnosis should be reported. Pertinent positive or negative laboratory results must be provided. When the reference range of a laboratory value is not widely known or established, it should be provided in parentheses. Diagnostic procedures, the timeline in which they were administered, and a brief report of the results should be included. A verbatim description of a pathologist’s report must not be used; instead, a salient report of the results should be included. Pictures of histopathology, roentgenograms, electrocardiographs, and other diagnostic tests; skin manifestations; wounds; and other anatomical parts may be provided and add to the interest of the report. Any identifying features of a patient’s photograph should be blocked out. Institutional policies and patient permission for obtaining and using photographs must be followed.

Patient’s medication history

The patient’s medication history should include the medication’s name, strength, dosage form, route, and dates of administration. The brand or generic name of the drug and the name of the manufacturer may be relevant to the case and should be listed. Brand and generic drugs may have different bioavailability factors or may contain different fillers, preservatives, additives, or dyes—all of which may be pertinent to cases regarding the drugs’ pharmacokinetics, efficacy, and adverse effects. Since a medication history may often omit herbals, vaccines, depot injections, and nonprescription medications, the author should specify the history of each of these medication types. The dates a medication was discontinued should be identified, since medications may have lasting effects for months after discontinuation. The author should verify and inform the reader of the patient’s history of medication adherence.

In order to evaluate the appropriateness of a medication’s dosage regimen, laboratory values that describe renal and hepatic organ functions should be provided. Renal function values should include serum creatinine, blood urea nitrogen, and the total fluid volume intake and excretion when a urinary catheter is in place. Calculation methods used to estimate the patient’s renal function should be identified. Liver function tests such as the International Normalized Ratio, serum albumin, and albumin:globulin ratio and hepatic enzyme tests such as aspartate and alanine aminotransferases should be provided.

A comprehensive medication history should also include the patient’s allergy status. The allergy history should include the date of the reaction, the name of the drug, and the type of allergic manifestation. The name of the drug should be listed as either the generic or brand name, and combination products should be listed as such. Allergies to combination products such as Unasyn and Zosyn can be mislabeled as a penicillin allergy rather than a sulfone allergy or vice versa. Similarly, an allergy to Septra or Bactrim can be mislabeled as an allergy to sulfonamide rather than to trimethoprim or vice versa. Some nonallergic adverse drug reactions such as drug-induced seizures may not be included in the allergy history; nevertheless, the author should investigate and report such data.

When available, drug serum levels ought to be listed along with the time they were drawn and their relationship to the dosage of the medication administered (e.g., trough, peak). Drug serum levels should delineate between total and free levels (e.g., phenytoin, valproic acid). Since there may be intralaboratory variations in drug serum reference ranges, the reference range should always be provided in parentheses. When pertinent to the case, the method of drug serum level assay should also be included.

Patient’s diet

The patient’s diet history ought to be included in the case report. Food can interact with medications, yielding lower or higher serum drug levels or increasing or decreasing the drug’s pharmacologic effect. The patient’s diet can have consequential effects on a disease state. Dietary causes of adverse events, such as allergic reactions, should be ruled out before suspecting a drug allergy.

The discussion section is the most important section of the case report. The discussion should evaluate the patient case for accuracy, validity, and uniqueness; compare and contrast the case report with the published literature; and derive new knowledge and applicability to practice. The author must confirm that the case report is valid by ensuring the accuracy of the data presented and by establishing a temporal and causal relationship. For drug-induced adverse effects, a validated nomogram to establish the probability of causality such as the Naranjo nomogram must be used. 8

The author should comprehensively list the limitations of the case and should describe the significance of each limitation. The author should briefly summarize the published literature derived from the literature review and may provide a detailed summary of a few citations. A table listing the pertinent facts of the cases detected from the literature review is a simple method for providing extensive, detailed data in an interpretable form. The author should compare and contrast the nuances of the case report with the published literature and should explain and justify the differences and similarities. The discussion section of a case report is in no way designed to provide comprehensive details of each citation of an all-inclusive and extensive literature review—this should be saved for review articles. All the references cited should be critically evaluated. Transferring an unread reference cited in another article is unethical and will place the author of the case report at risk of error and embarrassment.

The author should next summarize the essential features of the case report, justify why this case is unique, and draw recommendations and conclusions.

Based on the evidence reviewed in the discussion section, the author must provide a justified conclusion. The author must be careful not to make firm judgments and sweeping recommendations based on speculation, on limited and tenuous information, or on a few case reports. However, justifiable evidence-based recommendations should be stated. The author may suggest that clinicians be cognizant of the insight learned from the case or suggest heightened vigilance, prudent management, avoidance, further study before taking action, or new ideas for investigation. How the information discovered from the case report will apply to the author’s practice should be described. This section should be concise and not exceed one paragraph. Guidelines for writing patient case reports in a checklist format (Appendix B) can facilitate and enhance the manuscript writing process.

Patient case reports are valuable resources of new and unusual information that may lead to vital research and advances in clinical practice that improve patient outcomes. Case reports should contain an abstract and four sections—an introduction, case presentation, discussion, and conclusion. The introduction provides the subject, purpose, and merit of the case report and the strategy used for the literature review. The patient case presentation should be descriptive, organized chronologically, accurate, salient, and presented in a narrative form. The discussion should compare and contrast the case report’s findings with the literature review, establish a causal and temporal relationship, and validate the case with a probability scale. The literature review should be extensive and should support the justification of the case report. The discussion section should end with a brief summary of the case with rational recommendations and conclusions. The conclusion section must provide a brief conclusion with evidence-based recommendations.

Patient case reports are valuable resources of new and unusual information that may lead to vital research.

Publishable patient case reports include cases that:

Advance medical science and spawn research;

Describe rare, perplexing, or novel diagnostic features of a disease state;

Report therapeutic challenges, controversies, or dilemmas;

Describe a new surgical procedure;

Report how a drug can enhance a surgical procedure;

Teach humanistic lessons to the health care professional;

Review a unique job description of a health care professional that improves patient care;

Report new medical errors or medication errors;

Discover a device malfunction that results in patient harm;

Describe adverse effects and patient toxicity of a radiopaque agent;

Describe life-threatening adverse events;

Describe dangerous and predictable adverse effects that are poorly appreciated and rarely recognized;

Describe rare or novel adverse drug reactions;

Describe a therapeutic failure or a lack of therapeutic efficacy;

Describe rare or novel drug–drug, drug–food, or drug–nutrient interactions;

Report unlabeled or unapproved uses of a medication;

Explore the use of pharmacogenomics to manage diseases;

Use life-saving techniques not previously documented;

Use pharmacoeconomic principles that improve patient care;

Uncover barriers to patient adherence;

Discover an interaction between a drug and a laboratory test that yields a false-positive or false-negative result;

Describe the effect of drugs in pregnancy and lactation;

Detect novel pharmacokinetic or pharmacodynamic principles; and

Use technology to improve patient outcomes.

(The following checklist is comprehensive; some items may not apply to all types of case reports.)

I. Abstract

□ Introduction and objective.

□ Case report.

□ Discussion.

□ Conclusion.

II. Introduction

□ Describe the subject matter.

□ State the purpose of the case report.

□ Provide background information.

□ Provide pertinent definitions.

□ Describe the strategy of the literature review and provide search terms.

□ Justify the merit of the case report by using the literature review.

□ Introduce the patient case to the reader.

□ Make the introduction brief and less than three paragraphs.

III. Patient case presentation

□ Describe the case in a narrative form.

□ Provide patient demographics (age, sex, height, weight, race, occupation).

□ Avoid patient identifiers (date of birth, initials).

□ Describe the patient’s complaint.

□ List the patient’s present illness.

□ List the patient’s medical history.

□ List the patient’s family history.

□ List the patient’s social history.

□ List the patient’s medication history before admission and throughout the case report.

□ Ensure that the medication history includes herbals, vaccines, depot injections, and nonprescription medications, and state that the patient was asked for this history.

□ List each drug’s name, strength, dosage form, route, and dates of administration.

□ Verify the patient’s medication adherence.

□ Provide renal and hepatic organ function data in order to determine the appropriateness of medication dosing regimens.

□ List the patient’s drug allergy status, including the name of the drug (brand or generic) and the date and type of reaction.

□ List the patient’s adverse drug reaction history and the dates of the reaction.

□ Provide pertinent serum drug levels and include the time of each level taken and its relationship to a dose.

□ Provide the patient’s dietary history.

□ Provide pertinent findings on physical examination.

□ Provide pertinent laboratory values that support the case.

□ Provide the reference range for laboratory values that are not widely known or established.

□ List the completed diagnostic procedures that are pertinent and support the case.

□ Paraphrase the salient results of the diagnostic procedures.

□ Provide photographs of histopathology, roentgenograms, electrocardiograms, skin manifestations, or anatomy as they relate to the case.

□ Obtain permission from the patient to use the patient’s photographs, or follow institutional guidelines.

□ Provide the patient’s events in chronological order.

□ Ensure a temporal relationship.

□ Ensure a causal relationship.

□ Ensure that the patient case presentation provides enough detail for the reader to establish the case’s validity.

IV. Discussion

□ Compare and contrast the nuances of the case report with the literature review.

□ Explain or justify the similarities and differences between the case report and the literature.

□ List the limitations of the case report and describe their relevance.

□ Confirm the accuracy of the descriptive patient case report.

□ Establish a temporal relationship.

□ Establish a causal relationship.

□ Report the validity of the case report by applying a probability scale such as the Naranjo nomogram.

□ Summarize the salient features of the case report.

□ Justify the uniqueness of the case.

□ Draw recommendations and conclusions.

V. Conclusion

□ Provide a justified conclusion.

□ Provide evidence-based recommendations.

□ Describe how the information learned applies to one’s own practice.

□ List opportunities for research.

□ Ensure that this section is brief and does not exceed one paragraph.

Gottleib GJ, Rogoz A, Vogel JV et al. A preliminary communication on extensively disseminated Kaposi’s sarcoma in a young homosexual man. Am J Dermatopathol . 1981 ; 3 : 111 –4.

Douglas J, Munro J, Kitchin A et al. Pulmonary hypertension and fenfluramine. Br Med J . 1981 ; 283 : 881 –3.

Atanasson P, Weiss B, Schmid E et al. Pulmonary hypertension and dexfenfluramine. Lancet . 1992 ; 339 : 436 . Letter.

Weir EK, Reeve HL, Huang JM et al. Anorexic agents aminorex, fenfluramine, and dexfenfluramine inhibit potassium current in rat pulmonary vascular smooth muscle and cause pulmonary vasoconstriction. Circulation . 1996 ; 94 : 2216 –20.

Abenhaim L, Moride Y, Brenot F et al. Appetite-suppressant drugs and the risk of primary pulmonary hypertension. N Engl J Med . 1996 ; 335 : 609 –16.

DeBakey L, DeBakey S. The case report. I. Guidelines for preparation. Int J Cardiol . 1983 ; 4 : 357 –64.

McCarthy LH, Reilly KE. How to write a case report. Fam Med . 2000 ; 329 : 190 –5.

Naranjo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther . 1981 ; 30 : 239 –45.

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How to Write a Medical Case Study Report

Last Updated: July 5, 2022 Fact Checked

This article was medically reviewed by Mark Ziats, MD, PhD and by wikiHow staff writer, Jennifer Mueller, JD . Dr. Mark Ziats is an Internal Medicine Physician, Scientist, Entrepreneur, and the Medical Director of xBiotech. With over five years of experience, he specializes in biotechnology, genomics, and medical devices. He earned a Doctor of Medicine degree from Baylor College of Medicine, a Ph.D. in Genetics from the University of Cambridge, and a BS in Biochemistry and Chemistry from Clemson University. He also completed the INNoVATE Program in Biotechnology Entrepreneurship at The Johns Hopkins University - Carey Business School. Dr. Ziats is board certified by the American Board of Internal Medicine. There are 16 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 186,121 times.

You've encountered an interesting and unusual case on your rounds, and a colleague or supervising physician says, "Why don't you write up a case study report?" If you've never written one before, that might sound intimidating, but it's a great way to get started in medical writing. Case studies always follow a standard structure and format, so the writing is very formulaic once you get the hang of it. Read on for a step-by-step guide to writing your first case study report.

What is a case study report?

• Medical students or residents typically do the bulk of the writing of the report. If you're just starting your medical career, a case study report is a great way to get a publication under your belt. [2] X Research source

• If the patient is a minor or is incapable of giving informed consent, get consent from their parents or closest relative. [4] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source
• Your hospital likely has specific consent forms to use. Ask your supervising physician if you're not sure where to get one.
• Some journals also have their own consent form. Check your target journal's author or submission information to make sure. [5] X Research source

How is a case study report structured?

• Even though the introduction is the first part of a case study report, doctors typically write it last. You'll have a better idea of how to introduce your case study to readers after you've written it.
• Your abstract comes at the top, before the introduction, and provides a brief summary of the entire report. Unless your case study is published in an open-access journal, the abstract is the only part of the article many readers will see.

• Many journals offer templates and checklists you can use to make sure your case study includes everything necessary and is formatted properly—take advantage of these! Some journals, such as BMJ Case Reports , require all case studies submitted to use their templates.

Drafting Your Medical Case Study Report

• Patient description
• Chronological case history
• Physical exam results
• Results of any pathological tests, imaging, or other investigations
• Treatment plan
• Expected outcome of treatment
• Actual outcome of treatment

• Why the patient sought medical help (you can even use their own words)
• Important information that helped you settle on your diagnosis
• The results of your clinical examination, including diagnostic tests and their results, along with any helpful images
• A description of the treatment plan
• The outcome, including how and why treatment ended and how long the patient was under your care [11] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

• You will need references to back up symptoms of the condition, common treatment, and the expected outcome of that common treatment.
• Use your research to paint a picture of the usual case of a patient with a similar condition—it'll help you show how unusual and different your patient's case is.
• Generally, aim for around 20 references—no fewer than 15, but no more than 25. [13] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

• Close your discussion section with a summary of the lessons learned from the case and why it's significant to consider when treating similar cases in the future.
• Outline any open questions that remain. You might also provide suggestions for future research.

• In your conclusion, you might also give suggestions or recommendations to readers based on what you learned as a result of the case.
• Some journals don't want a separate conclusion section. If that's the case for one of your target journals, just move this paragraph to the end of your discussion section.

Polishing Your Report for Submission to Publishers

• Most titles are fewer than 10 words long and include the name of the disease or condition treated.
• You might also include the treatment used and whether the outcome was successful. When deciding what to include, think about the reason you wrote the case study in the first place and why you think it's important for other clinicians to read.

• Made a significant intellectual contribution to the case study report
• Was involved in the medical care of the patient reported
• Can explain and defend the data presented in the report
• Has approved the final manuscript before submission for publication

• Keep in mind that the abstract is not just going to be the first thing people read—it will often be the only thing people read. Make sure that if someone is going to walk away having only read the abstract, they'll still get the same message they would have if they read the whole thing.
• There are 2 basic types of abstract: narrative and structured. A narrative abstract is a single paragraph written in narrative prose. A structured abstract includes headings that correspond with the sections of the paper, then a brief summary of each section. Use the format preferred by your target journal.

• Look for keywords that are relevant to your field or sub-field and directly related to the content of your article, such as the name of the condition or specific treatments you used.
• Most journals allow 4-8 keywords but check the submission guidelines of your target journal to make sure.

• Blur out the patient's face as well as any tattoos, birthmarks, or unrelated scars that are visible in diagnostic images.

• It's common to thank the patient, but that's up to you. Even if you don't, include a statement indicating that you have the patient's written, informed consent to publish the information.
• Read the journal's submission guidelines for a definition of what that journal considers a conflict of interest. They're generally the same, but some might be stricter than others. [22] X Research source

• If you're not familiar with the citation style used by your target journal, check online for a guide. There might also be one available at your hospital or medical school library.
• Medical librarians can also help with citation style and references if you run into something tricky—don't just wing it! Correct citation style insures that readers can access the materials you cite.

• It's also a good idea to get a beta reader who isn't a medical professional. Their comments can help you figure out where you need to clarify your points.
• Read a lot of case studies published in your target journals—it will help you internalize the tone and style that journal is looking for.

Submitting Your Report to Publishers

• Look into the background and reputation of journals before you decide to submit to them. Only seek publication from reputable journals in which articles go through a peer-review process.
• Find out what publishing fees the journals charge. Keep in mind that open-access journals tend to charge higher publishing fees. [26] X Research source
• Read each journal's submission and editorial guidelines carefully. They'll tell you exactly how to format your case study, how long each section should be, and what citation style to use. [27] X Research source
• For electronic journals that only publish case reports, try BMJ Case Reports , Journal of Medical Case Reports , or Radiology Case Reports .

• If your manuscript isn't suitable for the journal you submitted to, the journal might offer to forward it to an associated journal where it would be a better fit.
• When your manuscript is provisionally accepted, the journal will send it to other doctors for evaluation under the peer-review process.
• Most medical journals don't accept simultaneous submissions, meaning you'll have to submit to your first choice, wait for their decision, then move to the next journal on the list if they don't bite.

• Along with your revised manuscript, include a letter with your response to each of the reviewer's comments. Where you made revisions, add page numbers to indicate where the revisions are that address that reviewer's comments.
• Sometimes, doctors involved in the peer review process will indicate that the journal should reject the manuscript. If that's the case, you'll get a letter explaining why your case study report won't be published and you're free to submit it elsewhere.

• Some journals require you to have your article professionally copy-edited at your own cost while others do this in-house. The editors will let you know what you're responsible for.

• With your acceptance letter, you'll get instructions on how to make payment and how much you owe. Take note of the deadline and make sure you pay it as soon as possible to avoid publication delays.
• Some journals will publish for free, with an "open-access option" that allows you to pay a fee only if you want open access to your article. [32] X Research source

• Through the publishing agreement, you assign your copyright in the article to the journal. This allows the journal to legally publish your work. That assignment can be exclusive or non-exclusive and may only last for a specific term. Read these details carefully!
• If you published an open-access article, you don't assign the copyright to the publisher. The publishing agreement merely gives the journal the right to publish the "Version of Record." [34] X Research source

How do I find a suitable case for a report?

• A rare disease, or unusual presentation of any disease
• An unusual combination of diseases or conditions
• A difficult or inconclusive diagnosis
• Unexpected developments or responses to treatment
• Personal impact
• Observations that shed new light on the patient's disease or condition

• There might be other members of your medical team that want to help with writing. If so, use one of these brainstorming sessions to divvy up writing responsibilities in a way that makes the most sense given your relative skills and experience.
• Senior doctors might also be able to name some journals that would potentially publish your case study. [37] X Research source

Expert Q&A

You Might Also Like

• ↑ https://www.elsevier.com/connect/authors-update/the-dos-and-donts-of-writing-and-publishing-case-reports
• ↑ https://www.bmj.com/content/350/bmj.h2693
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686928/
• ↑ https://health.usf.edu/medicine/internalmedicine/im-impact/~/media/B3A3421F4C144FA090AE965C21791A3C.ashx
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476221/
• ↑ https://www.springer.com/gp/authors-editors/authorandreviewertutorials/writing-a-journal-manuscript/title-abstract-and-keywords/10285522
• ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
• ↑ https://thelancet.com/pb/assets/raw/Lancet/authors/tl-info-for-authors.pdf
• ↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-017-1351-y
• ↑ https://guides.himmelfarb.gwu.edu/casereports
• ↑ https://casereports.bmj.com/pages/authors/
• ↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-7-239
• ↑ https://research.chm.msu.edu/students-residents/writing-a-case-report
• ↑ https://www.elsevier.com/__data/assets/pdf_file/0006/98619/Sample-P-copyright-2.pdf
• ↑ https://authorservices.taylorandfrancis.com/publishing-your-research/moving-through-production/copyright-for-journal-authors/#

About This Article

Medical Disclaimer

The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment.

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To start a medical case study report, first choose a title that clearly reflects the contents of the report. You’ll also need to list any participating authors and develop a list of keywords, as well as an abstract summarizing the report. Your report will need to include an introduction summarizing the context of the report, as well as a detailed presentation of the case. Don’t forget to include a thorough citation list and acknowledgements of anyone else who participated in the study. For more tips from our Medical co-author, including how to get your case study report published, keep reading! Did this summary help you? Yes No

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How to Write Your First Clinical Case Report

What Is a Clinical Case Report?

Clinical case reports are instructional documents written by clinicians, often with assistance from medical writers who are experienced in writing scientific publications. Clinical case reports, which are published in medical journals, present a detailed description of an interesting or unusual patient case.    These documents are a way to spread new observations and knowledge throughout the medical community, whether to experienced medical practitioners, students, or other health care professionals.

Throughout their years of work, medical practitioners come across a variety of puzzling or complex illnesses, side effects, and patient cases. Whenever an unusual or noteworthy case occurs, there’s an opportunity for the case to help teach other medical professionals about the physician’s observations, diagnosis, and treatment plan. A written report of the patient case and resulting treatment and outcome is called a clinical case report.  

How Should I Structure a Clinical Case Report?

Fortunately, writing a clinical case report is not a guessing game. The CARE guidelines (for CAse REports) were last published in the Journal of Clinical Epidemiology in 2017. These guidelines, which were developed by an international group of experts, were first laid out in 2013. These guidelines were designed to support consistency, accuracy, and the potential for peer review and publication in medical journals. 

The CARE guidelines are an invaluable resource for new and veteran medical writers. The CARE checklist for clinical case reports outlines 13 document sections to include in a clinical case report.  Medical writers interested in crafting a clinical case report should download and print the entire checklist. It’s a helpful tool to keep handy at your desk.

Keep in mind that every medical journal has its own guidelines for what to include in a clinical case report and how to structure the document. Nevertheless, the focus should be the patient and what was unique about the case. The case presentation should be concise, with clear take‑away messages that clinicians can put into practice.

4 Keys for Successful Clinical Case Report Writing 

The CARE guidelines will help you structure your clinical case report, but there is also an art to these documents. Below, we outline four keys for a successful approach to the research and writing processes.

1. Prepare to ask a lot of questions

As you assist authors, one of the most important ways to set yourself up for success is to ask plenty of questions, including:

• What key takeaway message will this clinical case report address for clinicians?
• What can you assume readers will already know?
• What new information will this case add to the existing literature?

It’s important to seek expert input so that you don’t miss or misrepresent critical information. Do you know the standard and abnormal values for related laboratory tests? Do you thoroughly understand the symptoms and treatment methods used in the case?

2. Think like a journalist

More than perhaps any other type of medical document, a clinical case report tells a story. Answer the basic questions covered in all news stories:

Journalists also carefully consider which details are important to the story. Some descriptions and human‑interest details help make the case compelling. Other details might distract the reader or add a sheen of drama that feels inappropriate for a clinical case report. 

3. Add visuals

Clinical case reports are learning tools. Adding photographs, X‑ray images, or other medical visuals will augment the document’s appeal and learning potential. 

Remind authors to get consent before using anything from patient records. It’s also important to block out all identifying information.

4. Seek acknowledgement

April 19, 2021 at 9:00 AM

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How to present patient cases

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A guide on how to structure a case presentation

This article contains...

-History of presenting problem

-Medical and surgical history

-Drugs, including allergies to drugs

-Family history

-Social history

-Review of systems

-Findings on examination, including vital signs and observations

-Differential diagnosis/impression

-Investigations

-Management

Presenting patient cases is a key part of everyday clinical practice. A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical competence. 1

The purpose of a case presentation is to communicate your diagnostic reasoning to the listener, so that he or she has a clear picture of the patient’s condition and further management can be planned accordingly. 2 To give a high quality presentation you need to take a thorough history. Consultants make decisions about patient care based on information presented to them by junior members of the team, so the importance of accurately presenting your patient cannot be overemphasised.

As a medical student, you are likely to be asked to present in numerous settings. A formal case presentation may take place at a teaching session or even at a conference or scientific meeting. These presentations are usually thorough and have an accompanying PowerPoint presentation or poster. More often, case presentations take place on the wards or over the phone and tend to be brief, using only memory or short, handwritten notes as an aid.

Everyone has their own presenting style, and the context of the presentation will determine how much detail you need to put in. You should anticipate what information your senior colleagues will need to know about the patient’s history and the care he or she has received since admission, to enable them to make further management decisions. In this article, I use a fictitious case to show how you can structure case presentations, which can be adapted to different clinical and teaching settings (box 1).

Box 1: Structure for presenting patient cases

Presenting problem, history of presenting problem, medical and surgical history.

Drugs, including allergies to drugs

Family history

Social history, review of systems.

Findings on examination, including vital signs and observations

Differential diagnosis/impression

Investigations

Case: tom murphy.

You should start with a sentence that includes the patient’s name, sex (Mr/Ms), age, and presenting symptoms. In your presentation, you may want to include the patient’s main diagnosis if known—for example, “admitted with shortness of breath on a background of COPD [chronic obstructive pulmonary disease].” You should include any additional information that might give the presentation of symptoms further context, such as the patient’s profession, ethnic origin, recent travel, or chronic conditions.

“ Mr Tom Murphy is a 56 year old ex-smoker admitted with sudden onset central crushing chest pain that radiated down his left arm.”

In this section you should expand on the presenting problem. Use the SOCRATES mnemonic to help describe the pain (see box 2). If the patient has multiple problems, describe each in turn, covering one system at a time.

Box 2: SOCRATES—mnemonic for pain

Associations

Time course

Exacerbating/relieving factors

“ The pain started suddenly at 1 pm, when Mr Murphy was at his desk. The pain was dull in nature, and radiated down his left arm. He experienced shortness of breath and felt sweaty and clammy. His colleague phoned an ambulance. He rated the pain 9/10 in severity. In the ambulance he was given GTN [glyceryl trinitrate] spray under the tongue, which relieved the pain to 5/10. The pain lasted 30 minutes in total. No exacerbating factors were noted. Of note: Mr Murphy is an ex-smoker with a 20 pack year history”

Some patients have multiple comorbidities, and the most life threatening conditions should be mentioned first. They can also be categorised by organ system—for example, “has a long history of cardiovascular disease, having had a stroke, two TIAs [transient ischaemic attacks], and previous ACS [acute coronary syndrome].” For some conditions it can be worth stating whether a general practitioner or a specialist manages it, as this gives an indication of its severity.

In a surgical case, colleagues will be interested in exercise tolerance and any comorbidity that could affect the patient’s fitness for surgery and anaesthesia. If the patient has had any previous surgical procedures, mention whether there were any complications or reactions to anaesthesia.

“Mr Murphy has a history of type 2 diabetes, well controlled on metformin. He also has hypertension, managed with ramipril, and gout. Of note: he has no history of ischaemic heart disease (relevant negative) (see box 3).”

Box 3: Relevant negatives

Mention any relevant negatives that will help narrow down the differential diagnosis or could be important in the management of the patient, 3 such as any risk factors you know for the condition and any associations that you are aware of. For example, if the differential diagnosis includes a condition that you know can be hereditary, a relevant negative could be the lack of a family history. If the differential diagnosis includes cardiovascular disease, mention the cardiovascular risk factors such as body mass index, smoking, and high cholesterol.

Highlight any recent changes to the patient’s drugs because these could be a factor in the presenting problem. Mention any allergies to drugs or the patient’s non-compliance to a previously prescribed drug regimen.

To link the medical history and the drugs you might comment on them together, either here or in the medical history. “Mrs Walsh’s drugs include regular azathioprine for her rheumatoid arthritis.”Or, “His regular drugs are ramipril 5 mg once a day, metformin 1g three times a day, and allopurinol 200 mg once a day. He has no known drug allergies.”

If the family history is unrelated to the presenting problem, it is sufficient to say “no relevant family history noted.” For hereditary conditions more detail is needed.

“ Mr Murphy’s father experienced a fatal myocardial infarction aged 50.”

Social history should include the patient’s occupation; their smoking, alcohol, and illicit drug status; who they live with; their relationship status; and their sexual history, baseline mobility, and travel history. In an older patient, more detail is usually required, including whether or not they have carers, how often the carers help, and if they need to use walking aids.

“He works as an accountant and is an ex-smoker since five years ago with a 20 pack year history. He drinks about 14 units of alcohol a week. He denies any illicit drug use. He lives with his wife in a two storey house and is independent in all activities of daily living.”

Do not dwell on this section. If something comes up that is relevant to the presenting problem, it should be mentioned in the history of the presenting problem rather than here.

“Systems review showed long standing occasional lower back pain, responsive to paracetamol.”

Findings on examination

Initially, it can be useful to practise presenting the full examination to make sure you don’t leave anything out, but it is rare that you would need to present all the normal findings. Instead, focus on the most important main findings and any abnormalities.

“On examination the patient was comfortable at rest, heart sounds one and two were heard with no additional murmurs, heaves, or thrills. Jugular venous pressure was not raised. No peripheral oedema was noted and calves were soft and non-tender. Chest was clear on auscultation. Abdomen was soft and non-tender and normal bowel sounds were heard. GCS [Glasgow coma scale] was 15, pupils were equal and reactive to light [PEARL], cranial nerves 1-12 were intact, and he was moving all four limbs. Observations showed an early warning score of 1 for a tachycardia of 105 beats/ min. Blood pressure was 150/90 mm Hg, respiratory rate 18 breaths/min, saturations were 98% on room air, and he was apyrexial with a temperature of 36.8 ºC.”

Differential diagnoses

Mentioning one or two of the most likely diagnoses is sufficient. A useful phrase you can use is, “I would like to rule out,” especially when you suspect a more serious cause is in the differential diagnosis. “History and examination were in keeping with diverticular disease; however, I would like to rule out colorectal cancer in this patient.”

Remember common things are common, so try not to mention rare conditions first. Sometimes it is acceptable to report investigations you would do first, and then base your differential diagnosis on what the history and investigation findings tell you.

“My impression is acute coronary syndrome. The differential diagnosis includes other cardiovascular causes such as acute pericarditis, myocarditis, aortic stenosis, aortic dissection, and pulmonary embolism. Possible respiratory causes include pneumonia or pneumothorax. Gastrointestinal causes include oesophageal spasm, oesophagitis, gastro-oesophageal reflux disease, gastritis, cholecystitis, and acute pancreatitis. I would also consider a musculoskeletal cause for the pain.”

This section can include a summary of the investigations already performed and further investigations that you would like to request. “On the basis of these differentials, I would like to carry out the following investigations: 12 lead electrocardiography and blood tests, including full blood count, urea and electrolytes, clotting screen, troponin levels, lipid profile, and glycated haemoglobin levels. I would also book a chest radiograph and check the patient’s point of care blood glucose level.”

You should consider recommending investigations in a structured way, prioritising them by how long they take to perform and how easy it is to get them done and how long it takes for the results to come back. Put the quickest and easiest first: so bedside tests, electrocardiography, followed by blood tests, plain radiology, then special tests. You should always be able to explain why you would like to request a test. Mention the patient’s baseline test values if they are available, especially if the patient has a chronic condition—for example, give the patient’s creatinine levels if he or she has chronic kidney disease This shows the change over time and indicates the severity of the patient’s current condition.

“To further investigate these differentials, 12 lead electrocardiography was carried out, which showed ST segment depression in the anterior leads. Results of laboratory tests showed an initial troponin level of 85 µg/L, which increased to 1250 µg/L when repeated at six hours. Blood test results showed raised total cholesterol at 7.6 mmol /L and nil else. A chest radiograph showed clear lung fields. Blood glucose level was 6.3 mmol/L; a glycated haemoglobin test result is pending.”

Dependent on the case, you may need to describe the management plan so far or what further management you would recommend.“My management plan for this patient includes ACS [acute coronary syndrome] protocol, echocardiography, cardiology review, and treatment with high dose statins. If you are unsure what the management should be, you should say that you would discuss further with senior colleagues and the patient. At this point, check to see if there is a treatment escalation plan or a “do not attempt to resuscitate” order in place.

“Mr Murphy was given ACS protocol in the emergency department. An echocardiogram has been requested and he has been discussed with cardiology, who are going to come and see him. He has also been started on atorvastatin 80 mg nightly. Mr Murphy and his family are happy with this plan.”

The summary can be a concise recap of what you have presented beforehand or it can sometimes form a standalone presentation. Pick out salient points, such as positive findings—but also draw conclusions from what you highlight. Finish with a brief synopsis of the current situation (“currently pain free”) and next step (“awaiting cardiology review”). Do not trail off at the end, and state the diagnosis if you are confident you know what it is. If you are not sure what the diagnosis is then communicate this uncertainty and do not pretend to be more confident than you are. When possible, you should include the patient’s thoughts about the diagnosis, how they are feeling generally, and if they are happy with the management plan.

“In summary, Mr Murphy is a 56 year old man admitted with central crushing chest pain, radiating down his left arm, of 30 minutes’ duration. His cardiac risk factors include 20 pack year smoking history, positive family history, type 2 diabetes, and hypertension. Examination was normal other than tachycardia. However, 12 lead electrocardiography showed ST segment depression in the anterior leads and troponin rise from 85 to 250 µg/L. Acute coronary syndrome protocol was initiated and a diagnosis of NSTEMI [non-ST elevation myocardial infarction] was made. Mr Murphy is currently pain free and awaiting cardiology review.”

Originally published as: Student BMJ 2017;25:i4406

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed

• ↵ Green EH, Durning SJ, DeCherrie L, Fagan MJ, Sharpe B, Hershman W. Expectations for oral case presentations for clinical clerks: opinions of internal medicine clerkship directors. J Gen Intern Med 2009 ; 24 : 370 - 3 . doi:10.1007/s11606-008-0900-x   pmid:19139965 . OpenUrl CrossRef PubMed Web of Science
• ↵ Olaitan A, Okunade O, Corne J. How to present clinical cases. Student BMJ 2010;18:c1539.
• ↵ Gaillard F. The secret art of relevant negatives, Radiopedia 2016; http://radiopaedia.org/blog/the-secret-art-of-relevant-negatives .

Baltimore bridge collapse: a bridge engineer explains what happened, and what needs to change

Associate Professor, Civil Engineering, Monash University

Disclosure statement

Colin Caprani receives funding from the Department of Transport (Victoria) and the Level Crossing Removal Project. He is also Chair of the Confidential Reporting Scheme for Safer Structures - Australasia, Chair of the Australian Regional Group of the Institution of Structural Engineers, and Australian National Delegate for the International Association for Bridge and Structural Engineering.

Monash University provides funding as a founding partner of The Conversation AU.

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When the container ship MV Dali, 300 metres long and massing around 100,000 tonnes, lost power and slammed into one of the support piers of the Francis Scott Key Bridge in Baltimore, the bridge collapsed in moments . Six people are presumed dead, several others injured, and the city and region are expecting a months-long logistical nightmare in the absence of a crucial transport link.

It was a shocking event, not only for the public but for bridge engineers like me. We work very hard to ensure bridges are safe, and overall the probability of being injured or worse in a bridge collapse remains even lower than the chance of being struck by lightning.

However, the images from Baltimore are a reminder that safety can’t be taken for granted. We need to remain vigilant.

So why did this bridge collapse? And, just as importantly, how might we make other bridges more safe against such collapse?

A 20th century bridge meets a 21st century ship

The Francis Scott Key Bridge was built through the mid 1970s and opened in 1977. The main structure over the navigation channel is a “continuous truss bridge” in three sections or spans.

The bridge rests on four supports, two of which sit each side of the navigable waterway. It is these two piers that are critical to protect against ship impacts.

And indeed, there were two layers of protection: a so-called “dolphin” structure made from concrete, and a fender. The dolphins are in the water about 100 metres upstream and downstream of the piers. They are intended to be sacrificed in the event of a wayward ship, absorbing its energy and being deformed in the process but keeping the ship from hitting the bridge itself.

The fender is the last layer of protection. It is a structure made of timber and reinforced concrete placed around the main piers. Again, it is intended to absorb the energy of any impact.

Fenders are not intended to absorb impacts from very large vessels . And so when the MV Dali, weighing more than 100,000 tonnes, made it past the protective dolphins, it was simply far too massive for the fender to withstand.

Read more: I've captained ships into tight ports like Baltimore, and this is how captains like me work with harbor pilots to avoid deadly collisions

Video recordings show a cloud of dust appearing just before the bridge collapsed, which may well have been the fender disintegrating as it was crushed by the ship.

Once the massive ship had made it past both the dolphin and the fender, the pier – one of the bridge’s four main supports – was simply incapable of resisting the impact. Given the size of the vessel and its likely speed of around 8 knots (15 kilometres per hour), the impact force would have been around 20,000 tonnes .

Bridges are getting safer

This was not the first time a ship hit the Francis Scott Bridge. There was another collision in 1980 , damaging a fender badly enough that it had to be replaced.

Around the world, 35 major bridge collapses resulting in fatalities were caused by collisions between 1960 and 2015, according to a 2018 report from the World Association for Waterborne Transport Infrastructure. Collisions between ships and bridges in the 1970s and early 1980s led to a significant improvement in the design rules for protecting bridges from impact.

Further impacts in the 1970s and early 1980s instigated significant improvements in the design rules for impact.

The International Association for Bridge and Structural Engineering’s Ship Collision with Bridges guide, published in 1993, and the American Association of State Highway and Transporation Officials’ Guide Specification and Commentary for Vessel Collision Design of Highway Bridges (1991) changed how bridges were designed.

In Australia, the Australian Standard for Bridge Design (published in 2017) requires designers to think about the biggest vessel likely to come along in the next 100 years, and what would happen if it were heading for any bridge pier at full speed. Designers need to consider the result of both head-on collisions and side-on, glancing blows. As a result, many newer bridges protect their piers with entire human-made islands.

Of course, these improvements came too late to influence the design of the Francis Scott Key Bridge itself.

Lessons from disaster

So what are the lessons apparent at this early stage?

First, it’s clear the protection measures in place for this bridge were not enough to handle this ship impact. Today’s cargo ships are much bigger than those of the 1970s, and it seems likely the Francis Scott Key Bridge was not designed with a collision like this in mind.

So one lesson is that we need to consider how the vessels near our bridges are changing. This means we cannot just accept the structure as it was built, but ensure the protection measures around our bridges are evolving alongside the ships around them.

Second, and more generally, we must remain vigilant in managing our bridges. I’ve written previously about the current level of safety of Australian bridges, but also about how we can do better.

This tragic event only emphasises the need to spend more on maintaining our ageing infrastructure. This is the only way to ensure it remains safe and functional for the demands we put on it today.

• Engineering
• Infrastructure
• Urban infrastructure
• container ships
• Baltimore bridge collapse

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