A Guide to Writing Quality Case Reports

Chait et al. HCA Healthcare Journal of Medicine (2023) 4:1

https://doi.org/10.36518/2689-0216.1485

Education

Robert Chait, MD, FACC, FACP

1,2

; Graig Donini

; Michael G. Flynn, PhD

Abstract

Description

Case reports play an essential role in the dissemination of knowledge in medicine. A pub-

lished case is typically an unusual or unexpected presentation in which the outcomes, clinical

course, and prognosis are linked to a literature review in order to place the case into the

appropriate context. Case reports are a good option for new writers to generate scholarly

output. This article can serve as a template for writing a case report, which includes instruc-

tions for creating the abstract and craing the body of the case report—introduction, case

presentation, and discussion. Instructions for writing an eective cover letter to the journal

editor are also provided as well as a checklist to help authors prepare their case reports for

submission.

Keywords

case report; scholarly activity; scholarly communication; journal; graduate medical education;

GME; publishing

Author aliations are listed

at the end of this article.

Correspondence to:

Graig Donini

HCA Healthcare Graduate

Medical Education

2000 Health Park Drive

Brentwood, TN 37027

(Graig.Donini@

hcahealthcare.com)

www.hcahealthcarejournal.com

Emerald Medical Education

HCA Healthcare

Journal of Medicine

Introduction

Case reports are time-honored and play an es-

sential role in disseminating knowledge in med-

icine. Case reports are “…a detailed report of

the symptoms, signs, diagnosis, treatment, and

follow-up of an individual patient.”

A published

case typically involves an unusual or unexpect-

ed presentation, new treatment, or alternative

diagnostic imaging in which the outcomes,

clinical course, and prognosis are linked to a

literature review in order to place the case into

the appropriate context.

Case reports oen

provide the first discovery of, or insight into,

an emerging or rare disease. For example, the

first mention of HIV/AIDS in the medical liter-

ature came from a case series in 1980.

Relative

to randomized controlled trials, case reports

reside near the bottom of the “hierarchy of

evidence” pyramid.

In other words, they are

not expected to contribute to clinical guidelines

in the same way as randomized controlled trials

or observational studies. However, case reports

can provide insight into new diseases, associa-

tions, or treatments that might otherwise be

overlooked. Thus, they play a vital role in in-

creasing what we know and what we can learn

about new, emerging diseases, and they help

improve our management of patient care.

an eort to improve the quality of case report

submissions, we will describe the key elements

of a well-written case report.

How to Get Started

This article can serve as a template for writing

a case report for any publication. However, the

following details highlight specific require-

ments for case reports submitted to the

HCA Healthcare Journal of Medicine. When sub-

mitting to another journal, one should read the

author guidelines carefully before submitting.

The first step is selecting an appropriate case

that may merit publication as a case report.

The case may be a rare or unique clinical con-

dition, intervention, complication, or outcome.

The important point is that you have identi-

fied something worthy of communication to

the journal readership. For example, a clinician

might ask, “Would the findings from this case

cause me to consider a change in my practice?"

HCA Healthcare Journal of Medicine

Next, it is beneficial to perform a literature

search to determine if the case is novel and

will interest readers. Starting points include

finding the diagnosed condition on UpToDate®,

which will provide links to individual referenc-

es.

Subsequently, a more in-depth search of

specialty-specific references on free public

databases such as PubMed and the Cases

Database should be completed.

5,7,8

Aer these

initial searches, the authors should have the in-

formation they need to determine if their case

is suitable for publication.

The literature search should show that the case

meets one of the following criteria highlighted

in the Journal of Medical Case Reports:

• The case is unique in either the course or

treatment of the disease or describes a

unique presentation not previously de-

scribed in the medical literature.

• The patient’s side eects or reactions to

medication are unique and have not been

previously described in the literature.

• The patient’s symptoms were resistant to

conventional treatment, or the patient re-

sponded to a novel or previously unreport-

ed treatment.

• The patient’s symptom complexes were

not previously associated with a disease, or

there was an uncommon link between the

disease and symptoms.

A case report may be accepted for publica-

tion even if it does not strictly meet one of

the above criteria. Adhering too tightly to the

above criteria could prevent valuable informa-

tion from being disseminated to the medical

community. The case should be unusual, but it

is more important that it adds something to

the medical literature.

Word count limits vary by journal, with some

as low as 500 words or as high as 3000 words.

The word count of a case report submitted to

the HCA Healthcare Journal of Medicine should

be around 2000 words from the introduction

to the conclusion, excluding references, tables,

figures, and figure legends. The number of ta-

bles, figures, or images should be limited to 5,

and the references should be limited to 20. The

HCA Healthcare Journal of Medicine is an online

journal where length is not a major issue as

with a printed journal, but a concise case report

is essential for an audience of busy physicians.

Videos or additional figures/images may be

useful for the reader and can be included as

supplementary material for HCA Healthcare

Journal of Medicine submissions. Learning

objectives provide helpful information for the

reader and may be required for some journals.

The authors should consider including learning

objectives in their case reports or case series.

Patient Consent

Most journals that publish case reports require

patient consent, and some journals have their

own consent form. It is important to note that

consent is required to disclose protected health

information (PHI), which includes case informa-

tion and patient images. The HCA Healthcare

Journal of Medicine requires authors to submit

a patient consent form along with the case

report manuscript.

The Cover Letter

When required, a cover letter gives the editor

an introduction to the manuscript. The cover

letter is uploaded separately into the

HCA Healthcare Journal of Medicine submis-

sion portal and must include the title of the

manuscript. The authors should clearly and

concisely state why the case report quali-

fies for publication in the journal. This step

is where the authors can make a compelling

argument as to why the case is important and

why it should be published. Naturally, the in-

troduction section of the case report provides

a more detailed description of case-related lit-

erature. Thus, authors should only provide the

key elements in the cover letter for the benefit

of the editor. Finally, include all authors’ full

names, institutions, and email addresses in the

cover letter and identify at least one corre-

sponding author along with their address.

The Title

Provide a clear and concise description of the

case that is not more than 15 words in length.

Avoid abbreviations and redundancies in the

title and avoid hyperbole such as “Unique

Case” or “First Reported.” The title is the read-

er’s introduction to the case, likely the first or

only part they will read, and it should provide

a clear and accurate description of the case. It

is tempting to create a cute or clever title, but

researchers have reported that amusing titles

can obscure the important elements of the

Chait et al. (2023) 4:1. https://doi.org/10.36518/2689-0216.1485

case and make it less likely that the manuscript

will be read.

9,10

Remember that the case report

represents a patient, and their dignity should

be protected. A pertinent example is the title

from the paper, “A lucky catch: Fishhook injury

of the tongue.”

We contend that the title clev-

erness is inappropriate when it is considered

that the patient described was 13 months old.

The Abstract

Use headings in the abstract that match the

manuscript headings and provide a succinct

description of the case. As with the title, the

abstract should provide enough information to

ensure that the reader understands the scope

of the work before investing their time in read-

ing it. Ideally, the abstract should encourage

the reader to go further and read the details

of the case. The abstract is entered separately

into the HCA Healthcare Journal of Medicine

submission portal, but it should also be includ-

ed in the submitted manuscript file.

Abstract length and style dier by journal. An

abstract for the HCA Healthcare Journal of

Medicine must be a succinct description of the

key elements of the case and, therefore, should

not greatly exceed 300 words. References and

citations should not be used in the abstract and

only a small number of abbreviations should be

included. The abbreviations should be defined

for the first use and match those used in the

main manuscript.

The abstract should be presented in 3 sections:

introduction, case presentation, and conclusion.

The abstract's introduction section illustrates

the importance of the case and the rationale

for reporting it. The case presentation section

should be concise and focused, providing the

important details of the patient presentation,

including the patient’s age, biological sex, and

gender identity. Finally, the conclusions section

should provide a short statement that illus-

trates key elements of the case and its clinical

impacts.

Keywords

Provide 3 to 10 keywords that reflect the

primary content of the article. Keywords are

essential for indexing the manuscript and facil-

itating easy online retrieval. However, finding

and selecting appropriate keywords can be a

challenge. Checking keywords from abstracts

describing similar cases can be helpful, as can

using the National Library of Medicine (NLM)

Medical Subject Headings (MeSH) site. The lat-

ter is the NLM-controlled vocabulary thesaurus

for indexing PubMed citations.

Elements of a Case Report

The main text file of the case report should

begin with the title and the abstract. The

HCA Healthcare Journal of Medicine uses a

double-blind peer review process in which the

authors and the reviewers are anonymous.

Thus, no author-identifying content should

be included in the main file, which is why it is

important to include the authors’ information

in the cover letter. The main sections of the

actual case report are the introduction, the

case presentation, and the discussion and con-

clusion. Each of these elements is described

below. If you are submitting to another jour-

nal, read their guidelines carefully as some

journals may have dierent rules for what to

include in the main text file.

The Introduction

The introduction should describe the back-

ground of the case, including the disease or dis-

order, its typical presentation and progression,

an explanation of the presentation in the case,

and whether it is a new disease. The introduc-

tion provides an opportunity to grab the read-

er’s attention and reiterate the importance of

the case. It should be concise and compel the

reader to go further. Make sure that all state-

ments of fact in the introduction are properly

cited.

The Case Presentation

When presenting the case, start with the

patient’s de-identified demographic informa-

tion, including age, biological sex, and gender

identity. We contend that the patient’s race

should not reflexively be included in the first

paragraph of the case description, unless race

is directly relevant to the case. In support of

this argument is a recent commentary in the

New England Journal of Medicine in which the

authors stated, “Clinically relevant and pa-

tient-specific socioeconomic considerations,

cultural beliefs, and race-related barriers to

high-quality health care should be acknowl-

edged and addressed later in the case presen-

tation.”

HCA Healthcare Journal of Medicine

Deidentifying a patient case in accordance

with the Health Insurance Portability and Ac-

countability Act (HIPAA) goes beyond simply

removing the patient’s name and date of birth.

The Safe Harbor method for deidentification

includes 18 items to remove, including geo-

graphic divisions smaller than a state, all ele-

ments of date (including date of service), age

above 90 (refer to the patient as “elderly” or

“over 89”), and any unique identifying number

(eg, medical record number [MRN]).

Describe the case concisely and in chronological

order, starting with the chief complaint and

significant family, occupational, and social his-

tory.

Provide key details of the patient’s pre-

sentation and clinical findings from the physical

exam, vitals at the time of examination, and

any images. Follow with significant labs and

tests and describe any treatments, procedures,

or interventions. Use standard measurement

units and include the normal range for positive

labs. When using abbreviations, spell out the

word for the first use, and use standard abbre-

viations when available. Also, use the generic

name for all medications unless a specific name

brand is the emphasis of the case.

Focus the case presentation on positive

findings from the history or exam, including

negative findings only when relevant to the

case or the diagnosis. Finish with a prognosis,

follow-up results, if available, and long-term

outcomes. Avoid superfluous or other extrane-

ous facts that detract from the understanding

of the case.

Tables are an eective way to present content

when there is a long list of tests/labs or sig-

nificant demographic or exam data to present.

Figures (or images) should be used to show

physical, microscopic, histological, or other visual

representations of the disease. Aer making

sure that no identifiable information is includ-

ed in a patient image, consider adding arrows

or another means of helping the reader locate

specific aspects of the images referred to in the

description. Refer to any tables or figures in this

section using targets or callouts (eg, “Figure 2”).

Tables and figures should be numbered se-

quentially in the order they are described in the

text. Tables should have a descriptive title, and

figures should include a caption that describes

the image in complete sentences.

The Discussion

The discussion is the authors’ opportunity to

distinguish key features of their case, highlight

its uniqueness, and identify and compare their

case to similar cases in the literature. Appropri-

ate comparisons can only be made if the litera-

ture is relevant and up to date. A similar case in

the literature does not necessarily detract from

the current case. Instead, it provides an oppor-

tunity to contrast and define unique elements

between cases. All statements of fact and any

literature presented must be properly cited in

the text.

Beyond these basics, the discussion provides

an opportunity to compare the current case to

previous literature, contrast findings with pre-

vious treatment strategies or outcomes, and

provide reasons for possible outcome dier-

ences. Authors of previously published works

likely had similar challenges and applied similar

strategies but may or may not have had the

same patient outcomes. The discussion also

provides the authors a chance to explain the

unique responses of their patients to medica-

tions or treatment and provide limited specula-

tion about their success or failure. In short, the

discussion is a chance for the authors to em-

ploy their clinical expertise to help the reader

understand the significance of their case and

how to respond should they see a similar case.

The Conclusion

The conclusion starts with a summary, includ-

ing key elements of the case and its clinical im-

pacts. Do not reiterate case details, but provide

a short statement to describe the case, course

of treatment, and outcomes. A concluding

statement should follow that highlights the rel-

evance of the case, whether it is generalizable,

and the contributions the case makes to the

literature or potential changes in treatment.

Construct your conclusion carefully, avoiding

overzealous statements, and make sure your

conclusion matches the content and tone ex-

pressed in the abstract conclusion.

References

The HCA Healthcare Journal of Medicine follows

American Medical Association (AMA) guidelines

for formatting and referencing. Briefly, refer-

ences are numbered consecutively by first use

in the main text, using commas to separate

when multiple sources are cited.

Chait et al. (2023) 4:1. https://doi.org/10.36518/2689-0216.1485

Authorship and Other

Contributions

As a general practice, case report authorship

is limited to physicians directly involved in the

case, and some journals limit the number of au-

thors. For a submission to the HCA Healthcare

Journal of Medicine, there should be no more

than 6 authors, without substantial justifica-

tion from the lead author.

An author is generally considered someone who

has made meaningful and substantive intel-

lectual contributions to a published study. The

International Committee of Medical Journal

Editors (ICMJE) has established guidelines for

authorship.

To qualify as an author, one should

have met the following 4 criteria:

• “Substantial contributions to the concep-

tion or design of the work; or the acquisi-

tion, analysis, or interpretation of data for

the work; AND

• Draing the work or revising it critically for

important intellectual content; AND

• Final approval of the version to be pub-

lished; AND

• Agreement to be accountable for all as-

pects of the work in ensuring that ques-

tions related to the accuracy or integrity

of any part of the work are appropriately

investigated and resolved”

Each author should have participated su-

ciently in the work to take public responsibility

for the content. It should also be noted that

acquiring or providing funding, data collection,

technical or lab support, providing access to

space, or supervision do not justify authorship.

Rather these activities meet the criteria for a

contributor to be acknowledged at the end of

the work.

It is highly recommended to use a medical

journal writing style and not typical prose that

is better le to college essays. Do not be overly

verbose but rather clear and concise. Authors

should enlist the help of colleagues (both clin-

ical and non-clinical) to act as proofreaders for

their manuscripts. Such editing is crucial for

presenting a clean and error-free manuscript,

giving the work a favorable reception from

editors and reviewers. It is recommended that

someone fluent in English review the manu-

script for style, syntax, and fluidity. Editing or

proofreading by itself does not qualify a per-

son to be an author, but these eorts can be

acknowledged at the end of the work.

Journal Submission and Review

Outcomes

The authors should carefully review the journal

information for authors prior to submitting

to a journal. The information for authors for

the HCA Healthcare Journal of Medicine can

be accessed using the following URL: https://

scholarlycommons.hcahealthcare.com/hca-

healthcarejournal/styleguide.html.

Aer the manuscript peer reviews are com-

pleted, the typical journal editor decisions are:

accept with minor revisions, major revisions

required, or reject. When major revisions are re-

quired, the manuscript is not accepted but may

be accepted if suitable revisions are made. In

this situation, authors should carefully respond

to each reviewer's comment in a point-by-

point fashion in a separate letter, providing a

list of responses for the reviewer to assess.

Authors should understand that reviewers are

making suggestions based on their experience

and knowledge. In most cases, the reviewer is

trying to help the authors improve the man-

uscript, not being abusive or demeaning, but

there are all too frequent cases of the latter.

either case, the authors’ responses to a review-

er should be polite and positive without being

obsequious. Whenever possible, the authors

should revise the manuscript as suggested

by the reviewers or they must provide a care-

ful explanation and their rationale when they

disagree with the reviewer. Follow the journal

instructions for uploading your revised manu-

script and reviewer letter(s).

Despite the authors’ best attempt to select

a unique case, it may be rejected if it is poorly

written or the editor or reviewers did not find

it compelling. Do not get discouraged by re-

jection. Take the advice oered in the rejection

letter and look for another journal that might

better fit the case. It is also possible that a por-

tion of the case, usually the images, could be

published in a journal that features visual media

or as a clinical image in the HCA Healthcare

Journal of Medicine.

HCA Healthcare Journal of Medicine

A Final Checklist for Case

Reports

The HCA Healthcare Journal of Medicine has

created a checklist to ensure the submitted

case report meets all the requirements for pub-

lication in the journal (Appendix A). The check-

list includes the elements presented in this

article, and completing it will help the editor to

move the work more quickly to peer review.

Conflicts of Interest

The authors declare that they have no conflicts

of interest.

Dr Chait is an employee of HCA Florida JFK

Hospital, a hospital aliated with the journal’s

publisher.

Dr Michael G. Flynn and Graig Donini are

employees of HCA Healthcare Graduate

Medical Education, an organization aliated

with the journal's publisher.

This research was supported (in whole or in

part) by HCA Healthcare and/or an

HCA Healthcare-aliated entity. The views

expressed in this publication represent those of

the author(s) and do not necessarily represent

the ocial views of HCA Healthcare or any of

its aliated entities.

Author Aliations

1. HCA Florida JFK Hospital, Miami, FL

2. University of Miami Miller School of

Medicine, Miami, FL

3. HCA Healthcare Graduate Medical

Education, Brentwood, TN

References

1. The Free Dictionary. Case report. Wikipe-

dia.org. Published 2014. Accessed March 9,

2022. https://encyclopedia.thefreedictio-

nary.com/case+report

2. The Free Dictionary. Case report. Medi-

cal Dictionary. Published 2009. Accessed

March 9, 2022. https://medical-dictionary.

thefreedictionary.com/case+report

3. Centers for Disease Control (CDC). Pneu-

mocystis pneumonia--Los Angeles. Morb

Mortal Wkly Rep. 1981;30(21):250-252.

4. Murad MH, Asi N, Alsawas M, Alahdab

F. New evidence pyramid. Evid Based

Med. 2016;21(4):125-127. doi: 10.1136/

ebmed-2016-110401

5. Rison RA. A guide to writing case re-

ports for the Journal of Medical Case

Reports and BioMed Central Research

Notes. J Med Case Rep. 2013;7(1):239.

doi:10.1186/1752-1947-7-239

6. Search - home page. In: Post TW, ed. Up-

ToDate. Waltham, Mass.: UpToDate, 2018.

Accessed March 9, 2022. www.uptodate.

com/contents/search

7. US National Library of Medicine. PubMed.

Accessed March 9, 2022. https://pubmed.

ncbi.nlm.nih.gov/

8. Ketterman E. Cases Database. J

Med Libr Assoc. 2014;102(2):137-138.

doi:10.3163/1536-5050.102.2.023

9. Subotic S, Mukherjee B. Short and

amusing: the relationship between

title characteristics, downloads,

and citations in psychology arti-

cles. J Inf Sci. 2014;40(1)115-124. doi:

10.1177/0165551513511393

10. Sagi I, Yechiam E. Amusing titles in

scientific journals and article cita-

tion. J Inf Sci. 2008;34(5):680-687.

doi:10.1177/0165551507086261

11. Eley KA, Dhariwal DK. A lucky catch:

fishhook injury of the tongue. J

Emerg Trauma Shock. 2010;3(1):92-93.

doi:10.4103/0974-2700.58653

12. US National Library of Medicine. Medical

Subject Headings. Accessed December

6, 2022. https://www.nlm.nih.gov/mesh/

meshhome.html

13. Brett AS, Goodman CW. First impres-

sions--should we include race or ethnicity

at the beginning of clinical case presen-

tations? N Engl J Med. 2021;385(27):2497-

2499. doi:10.1056/NEJMp2112312

14. Oce for Civil Rights Headquarters, US

Department of Health & Human Services.

Guidance regarding methods for de-iden-

tification of protected health information

in accordance with the Health Insurance

Portability and Accountability Act (HI-

PAA) Privacy Rule. Published Septem-

ber 7, 2012. Accessed December 6, 2022.

https://www.hhs.gov/hipaa/for-profes-

sionals/privacy/special-topics/de-identifi-

cation/index.html

15. AMA Manual of Style: A Guide for Authors

and Editors. 11th ed. Oxford University

Press; 2020.

16. International Committee of Medical

Journal Editors (ICMJE). Defining the

role of authors and contributors. Updat-

ed May 2022. Accessed March 16, 2022.

http://www.icmje.org/recommendations/

browse/roles-and-responsibilities/defin-

ing-the-role-of-authors-and-contributors.

html

Chait et al. (2023) 4:1. https://doi.org/10.36518/2689-0216.1485

17. Silbiger NJ, Stubler AD. Unprofessional

peer reviews disproportionately harm

underrepresented groups in STEM. PeerJ.

2019;7:e8247. doi:10.7717/peerj.8247

18. CARE Case Report Guidelines. 2013 CARE

Checklist. Published 2013. Accessed Feb-

ruary 17, 2022. https://www.care-state-

ment.org/checklist

HCA Healthcare Journal of Medicine

Appendix A: HCA Healthcare Journal of Medicine Checklist for Case Reports

Topic Description Reported on line

Cover Letter Submit a separate cover letter written to the editors should accompany the case report Yes No

Title Provide a clear and concise description of the case that is not more than 15 words in length

___________________

Keywords Provide up to 10 keywords, including the diagnosis and treatments

___________________

Informed consent a. Is patient permission provided with the submission? Yes No

b. Is patient information, including images, de-identified? Yes No

Abstract (shouldn’t

have citations)

a. Background: illustrate the importance of the case/rationale for reporting it

___________________

b. Case presentation: provide key details of patient’s presentation

___________________

c. Conclusion: illustrate the key elements of the case and its clinical impacts

___________________

Introduction (should

have citations)

Describe the background of the case, including the disease or disorder, its typical presentation

and progression, an explanation of the presentation, and whether it is a new disease

___________________

Case presentation a. Patient information: Symptoms, relevant demographics, relevant medical history

___________________

b. Clinical findings: physical exam and any images

___________________

c. Assessments: testing and diagnosis

___________________

d. Treatment: interventions and treatment plan

___________________

e. Follow-up and prognosis: follow-up information and outcomes if available

___________________

Discussion (should

have citations)

a. Describe other cases in the literature

___________________

b. Distinguish key features of the case, highlight its uniqueness, and identify and compare

the case to similar cases in the literature

___________________

Conclusion Include a paragraph that provides the ‘take home’ message the case provides

___________________