• Novelty of the case: The case should be rare or unusual in order to be of interest to other healthcare professionals.
• Significance of the case: The case is better when it is more prevalent.
• Completeness of the case: The case should be well-documented and should include all of the relevant information.
• Ethical considerations: It is important to consider the ethical implications of writing up a case report. For example, you should obtain the patient's consent before publishing the case report.

Case reports are commonly of the following categories:

• Rare diseases or causes
• Unusual presentation (symptom or symptomology) of disease
• Unusual combination of diseases (sometimes related)
• Difficult or inconclusive diagnosis
• Novel treatment  or challenges in treatment
• Anatomical variations

When presenting a case report, especially writing, the most important aspect of the write-up is telling the story related to the novelty.

A case report generally follows the following outline:

1. Introduction- (includes significance and novelty of the patient, the typical presentation of the disease, and/or the standard of care). The introduction is usually 2-3 paragraphs.
2. Case presentation (symptoms)- The presentation is usually 1 -2 paragraphs.
3. Observations (exam findings, patient history, and results of lab tests). Observations are usually 1 -2 paragraphs.
4. Diagnosis including differential- The Diagnosis section is usually 1 -2 paragraphs.
5. Treatment- The Treatment section is usually 1 -2 paragraphs.
6. Outcome- The Outcome section is usually 1 paragraph.
7. Discussion  (tied back to introduction). The Discussion may include an optional literature review. The Discussion is commonly 3-5 paragraphs.

A Case Report write-up is generally not challenging. Generally, the difficulty lies in the paperwork. A case report requires IRB approval. The IRB will grant an exemption for a case report when patient information is anonymized and/or patient consent is received. RVU uses Axiom mentor software for IRB processes (see handouts for help on submitting the IRB). A case study exception is relatively quick. Commonly, protected health information will be part of the case report write-up so that HIPAA will apply. RVU has a fax line to secure medical records in a HIPPA-compliant manner.

If possible, obtain informed consent before starting to write the case report. A blank patient consent form can be found on the RVU research website, or many journals or institutions have their own form. Some journals require their patient consent form (e.g., BMJ).

An excellent resource for case report write-ups is the CARE Guidelines at - https://www.care-statement.org/, including a checklist - https://www.care-statement.org/checklist. 

Clinical assistance is helpful but not required for writing up a case report. Commonly, students will ask preceptors, attendings, and residents for novel cases to write up.

Before beginning to write, identify a previously published case report that presents a case that is similar. Next outline the topic sentence from each paragraph and use as a guide through the writing process.   

An important step in this process is the selection of the journal to submit the case report. Journals have specific requirements and formats for submitting and publishing case reports. Consult the journal before starting to write. RVU has a relationship with BMJ Case Reports. If you do not have a journal in mind, using BMJ and the writing template is a good starting place. Journals commonly charge publication fees.