how do you write a patient case study

Writing a Patient Case Study: A Comprehensive Guide

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Writing a patient case study is a crucial aspect of medical research and analysis. A well-written and comprehensive case study provides valuable insights into patient conditions and contributes to the advancement of healthcare practices. In this guide, we will explore the importance of patient case studies, the ethical considerations involved, and the essential steps to take when preparing, conducting, and writing a patient case study.

Understanding the Importance of Patient Case Studies

Patient case studies play a vital role in medical research, helping researchers and healthcare professionals gain a deeper understanding of various medical conditions, treatment outcomes , and patient experiences. They serve as real-life examples that highlight different aspects of a medical case, including symptoms, diagnosis, treatment plans, and outcomes. By analyzing case studies, researchers can identify patterns, compare treatment methods, and ultimately improve patient care. Moreover, case studies are instrumental in medical education, offering students practical scenarios to apply theoretical knowledge.

The Role of Case Studies in Medical Research

In medical research, case studies serve as valuable evidence that contributes to the overall body of scientific knowledge. They allow researchers to examine rare conditions or unusual presentations, providing important insights that are not easily obtainable through other research methods. Case studies offer an opportunity to explore the complexities and nuances of medical diagnoses, treatments, and patient experiences in detail, ultimately leading to the development of evidence-based guidelines and improved clinical practices .

Ethical Considerations in Patient Case Studies

When conducting patient case studies, it is crucial to adhere to strict ethical standards. Patient confidentiality and informed consent are paramount. Researchers must ensure that patients' personal information remains confidential and that they have given informed consent to participate in the study. Additionally, the study design and methods must prioritize patient safety and well-being. Ethical considerations should guide every step of the case study process to ensure the protection of patients' rights and dignity.

Furthermore, patient case studies provide an opportunity for interdisciplinary collaboration within the medical field. In complex cases, healthcare professionals from different specialties come together to analyze the data and contribute their expertise. This collaborative approach enhances the quality of research and fosters a holistic understanding of the medical condition being studied.

Moreover, patient case studies can also shed light on the social and psychological impacts of healthcare. By examining the patient's experiences, researchers can gain insights into the impact of a medical condition on the individual's quality of life, mental well-being, and social support systems. This broader perspective helps healthcare professionals develop patient-centered approaches that address not only the physical aspects of the condition but also the emotional and social needs of the patient.

Preparing for Your Patient Case Study

Before embarking on a patient case study, careful preparation is necessary. This involves identifying a suitable patient and obtaining informed consent.

Undertaking a patient case study is a meticulous process that requires attention to detail and ethical considerations. To ensure the study's success and validity, it is crucial to delve deep into the selection process and consent acquisition.

Identifying a Suitable Patient

The selection of an appropriate patient for a case study is crucial. Ideally, the patient should have a condition that is relevant to the research topic and that showcases specific aspects of interest. It is essential to consider factors such as the availability of medical records , the uniqueness of the case, and ethical considerations. Collaborating with healthcare professionals and experts in the field can be beneficial in identifying suitable patients for your study.

Moreover, the process of identifying a suitable patient involves a comprehensive review of the medical history, diagnostic tests, and treatment plans. Understanding the nuances of the patient's condition and its implications on the research objectives is fundamental in creating a compelling case study.

Gaining Informed Consent

Prior to initiating the case study, obtaining informed consent from the patient is mandatory. Informed consent ensures that the patient fully understands the purpose of the study, the potential risks or benefits involved, and their rights as a participant. Researchers must provide clear and comprehensible information, allowing the patient ample time to consider their involvement. Additionally, it is essential to respect the patient's right to withdraw from the study at any given point without facing any consequences.

Furthermore, the process of gaining informed consent involves establishing a transparent and open dialogue with the patient. Addressing any concerns or queries they may have regarding the study can foster trust and cooperation, ultimately enhancing the quality of the case study.

Conducting the Patient Interview

The patient interview is a crucial part of gathering information for the case study. It allows researchers to obtain subjective details, delve into the patient's experiences, and gain insights into their condition.

When conducting a patient interview, it is essential for researchers to create a comfortable and welcoming environment. Patients may feel anxious or vulnerable, so establishing rapport and showing empathy can help them feel at ease. Building a trusting relationship with the patient can encourage open communication and lead to a more fruitful exchange of information.

Essential Questions to Ask

During the interview, it is important to ask a range of questions to gather comprehensive information. These may include inquiries about the patient's medical history, symptoms, lifestyle, and any factors that may have contributed to their condition. By asking open-ended questions, researchers encourage patients to share their personal experiences and provide valuable insights into their healthcare journey.

Moreover, it is crucial for researchers to actively listen during the interview. Paying attention to not just the words spoken but also the patient's tone, body language, and emotions can reveal additional nuances that may impact the understanding of the case. Empathetic listening demonstrates respect for the patient's perspective and can help researchers form a more holistic view of the individual's health concerns.

Recording and Transcribing the Interview

Accurate recording and transcription of the patient interview are crucial for maintaining the integrity of the case study. The use of audio recordings, with the patient's consent, ensures that important details are not missed or misconstrued. When transcribing the interview, researchers should be meticulous in capturing the patient's exact words, ensuring that any abbreviations or acronyms are correctly documented. This meticulous approach facilitates a comprehensive analysis of the case and promotes transparency in the research process.

Moreover, researchers should consider the ethical implications of recording and transcribing patient interviews . Respecting patient confidentiality and privacy is paramount, and measures should be in place to safeguard sensitive information. Clear guidelines on data storage, access, and disposal should be established to protect the integrity of the research and uphold the trust placed in the researchers by the patients.

Analysing the Patient's Medical History

Analyzing the patient's medical history is an essential step in understanding the context of their condition and treatment. It involves accessing and interpreting medical records and identifying key medical events.

Delving into a patient's medical history unveils a treasure trove of information that can shed light on their current health status. From the initial diagnosis to the latest treatment regimen, each entry in the medical records forms a piece of the puzzle that researchers meticulously piece together.

Interpreting Medical Records

The analysis of medical records offers a comprehensive overview of the patient's healthcare journey. Researchers must examine medical reports, laboratory results, imaging studies, and other relevant documentation. Careful evaluation of these records helps researchers understand the course of the disease, the efficacy of previous treatments, and any complications that may have arisen.

Medical records are akin to a detailed roadmap of the patient's health landscape, providing valuable insights into the twists and turns encountered along the way. Each blood test result, X-ray image, and specialist consultation note contributes to painting a holistic picture of the patient's medical narrative.

Identifying Key Medical Events

Within the patient's medical history, certain key events may have had a significant impact on their condition. By identifying these events, researchers can explore their relevance to the overall case study. Examples of key events may include surgeries, significant changes in symptoms, adverse reactions to medications, or responses to specific treatments. These events help shape the narrative of the case study and provide valuable insights into the patient's healthcare journey.

Unearthing these pivotal moments in a patient's medical history is akin to discovering hidden gems that unlock crucial chapters in their healthcare story. Each key event serves as a turning point, influencing subsequent decisions and treatments that shape the patient's medical trajectory.

Writing the Patient Case Study

Once all the necessary information has been gathered and analyzed, it is time to write the patient case study. A well-structured and concise case study allows for easy comprehension and dissemination of information.

Structuring Your Case Study

When structuring the case study, it is important to present the information in a logical manner. Begin with an introduction that sets the context of the case study and outlines its objectives. Follow this with a detailed description of the patient's medical history, including relevant diagnostic tests, treatments, and interventions. Describe the patient's progress, including any challenges or complications encountered along the way. Finally, conclude with an analysis of the case, highlighting key findings, lessons learned, and potential implications for future research or clinical practice.

Using Medical Terminology Correctly

Using appropriate medical terminology is essential in ensuring clarity and precision in your case study. When describing symptoms, diagnoses, treatments, and other medical concepts, use standard, approved terminology widely accepted in the medical community. This consistency facilitates better understanding and communication between researchers, healthcare professionals, and readers of the case study.

Furthermore, it is worth noting that the use of medical terminology also helps to maintain the integrity and professionalism of the case study. By adhering to established terminology, researchers can avoid confusion and ensure that their findings are accurately interpreted and applied in clinical settings.

Moreover, the correct use of medical terminology enhances the credibility of the case study. It demonstrates the author's expertise and knowledge in the field, lending weight to their conclusions and recommendations. This is particularly important when presenting case studies to medical professionals, who rely on accurate and precise language to make informed decisions about patient care.

In conclusion, writing a patient case study requires careful planning, ethical considerations, meticulous data collection, and effective communication. Patient case studies provide invaluable insights into medical conditions, contributing to the body of scientific knowledge and improving patient care and outcomes. By following this comprehensive guide, researchers can create informative and influential case studies that advance medical research and enhance clinical practices.

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How to Write a Medical Case Study Report

Last Updated: April 18, 2024 Approved

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 15 references cited in this article, which can be found at the bottom of the page. wikiHow marks an article as reader-approved once it receives enough positive feedback. In this case, 100% of readers who voted found the article helpful, earning it our reader-approved status. This article has been viewed 189,619 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." [33] 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. [36] 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://authorservices.taylorandfrancis.com/publishing-your-research/moving-through-production/copyright-for-journal-authors/#

About This Article

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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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• Published: 30 January 2023

A student guide to writing a case report

• Maeve McAllister 1  

BDJ Student volume  30 ,  pages 12–13 ( 2023 ) Cite this article

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As a student, it can be hard to know where to start when reading or writing a clinical case report either for university or out of special interest in a Journal. I have collated five top tips for writing an insightful and relevant case report.

A case report is a structured report of the clinical process of a patient's diagnostic pathway, including symptoms, signs, diagnosis, treatment planning (short and long term), clinical outcomes and follow-up. 1 Some of these case reports can sometimes have simple titles, to the more unusual, for example, 'Oral Tuberculosis', 'The escapee wisdom tooth', 'A difficult diagnosis'. They normally begin with the word 'Sir' and follow an introduction from this.

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Guidelines To Writing a Clinical Case Report. Heart Views 2017; 18 , 104-105.

British Dental Journal. Case reports. Available online at: www.nature.com/bdj/articles?searchType=journalSearch&sort=PubDate&type=case-report&page=2 (accessed August 17, 2022).

Chate R, Chate C. Achenbach's syndrome. Br Dent J 2021; 231: 147.

Abdulgani A, Muhamad, A-H and Watted N. Dental case report for publication; step by step. J Dent Med Sci 2014; 3 : 94-100.

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The do’s and don’ts of writing and publishing case reports

March 6, 2023 | 5 min read

Lessons from a recent Researcher Academy webinar

As a method of documenting a single clinical observation, case reports offer timely and valuable information, especially with regards to rare diseases. They show medical professionals how fellow practitioners have acted in similar situations and thus aid in the decision-making process by sharing best practices. Not only do they significantly contribute to the knowledge pool, they also help add to a researcher’s own publication portfolio. Producing a good case report requires much more than just an interesting case, however.

To assist researchers with this task, Professors Oliver Kurzai and Adilia Warris, editors of the journal  Medical Mycology Case Reports   opens in new tab/window  shared tips on writing high impact case reports in the latest Researcher Academy  webinar   opens in new tab/window . We are pleased to share here some quick do’s and don’ts from the webinar.

Tell a story

The best way to compose a case report is to tell a story. This can be accomplished by arranging the events in chronological order, being specific about your differential diagnostic considerations, elucidating the arguments for your clinical decision-making process, and following up to round off the story neatly. This will create an imaginary journey where your readers can follow every development of the case and understand why you have performed specific tests or made certain decisions during a particular treatment.

Get the details right

Make sure to describe the relevant signs and symptoms which have resulted in the differential diagnosis, both positive and negative in order to provide readers with the context in which you have made your decisions. You can also include in your case reports descriptions of actual values for blood test results, detailed dosages for medications prescribed or other variables that should be taken into account with respect to the outcome of the situation.

Employ pictures/figures where relevant

A picture, as they say, is worth a thousand words, especially for case reports where findings can be clearly and efficiently illustrated via images. Don’t make use of pictures without justification, however – do so only if they have a function. For example, macroscopic and microscopic images of a newly-identified causative microorganism are an essential whereas a picture of the model you have clearly explained elsewhere in the text may be overkill.

Formulate short and sharp titles

The title is the first selling point of your case report. Therefore, you would want it to be interesting and something that grasps the reader’s attention. Make sure you phrase it concisely, but still in an eye-catching way. Take a look at the examples shared by the speakers below.

An OK title: " Treatment of cerebral mucormycosis with drug therapy alone: a case report"

Versus a compelling title:  "Successful outcome of cerebral mucormycosis with drug therapy alone"

Secure written consent from patient

Due to its nature of being a detailed description of an individual patient’s clinical presentation and therapy, a case report almost always contains information that could be traced back to the individual in question. Thus, a written, informed consent from the patient is a key requirement for the publication. Keep in mind that your patient is your partner in completing a case report, therefore make sure to discuss the report proactively with them including being explicit about any potential images that you are going to use, especially if they show or could identify the patient.

Don’t write your case report before doing your homework

If your case is not unique or interesting enough, there is a high chance that it will not be published. Even when your case is unique but is not well-documented or misses some crucial diagnostic elements, the same outcome might still ensue. This is not only a waste of your precious time but also a discouragement which might prevent you from producing more case reports in the future. To avoid this outcome, make sure to carry out careful research  before  writing your case reports. Make sure it meets all necessary characteristics and requirements before spending a lot of time and effort on the writing part.

Don’t publish a case report without the patient’s consent

As explained above, informed patient consent is mandatory for the publication of your case reports. Ignoring this requirement can result in a rejection for your work and worse, ruin your relationship and reputation with patients. However, there is an exception for publishing a case report without patient consent when the benefit of publication toward to society outweighs potential harm for individual. This happens when the case report contains an extremely important public health message but impossible to obtain informed consent despite all efforts as the patient has died, for example.

Don’t forget, moreover that clinical practitioners are not required to, and should not reveal personal patient information to a journal that is not relevant to the case.

Don’t include everything

“Less is more” goes the popular adage… It is not recommended to provide an extensive overview or discuss every single aspect of the patient’s disease in the introduction and conclusion. This will only serve to disengage readers and will distract them from the main ideas you want to communicate. If you want to give a focused introduction and discussion, make sure your case report mentions only the key messages and information related and relevant to these points.

To learn more about other insightful tips on how to write influential case reports and more importantly to get them published, you can watch the full webinar recording at the  Researcher Academy   opens in new tab/window . If, after doing so you still have unresolved questions, why not post in the  Researcher Academy Mendeley group   opens in new tab/window , where the team will endeavour to find expert answers for you.

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How to write a patient case report

Affiliation.

• 1 Arnold & Marie Schwartz College of Pharmacy & Health Sciences, Long Island University, Brooklyn, NY 11203, USA. [email protected]
• PMID: 16990637
• DOI: 10.2146/ajhp060182

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.

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• Published: 06 April 2016

How to review a case report

• Rakesh Garg 1 ,
• Shaheen E. Lakhan 2 &
• Ananda K. Dhanasekaran 3  

Journal of Medical Case Reports volume  10 , Article number:  88 ( 2016 ) Cite this article

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Peer Review reports

Introduction

Sharing individual patient experiences with clinical colleagues is an essential component of learning from each other. This sharing of information may be made global by reporting in a scientific journal. In medicine, patient management decisions are generally based on the evidence available for use of a particular investigation or technology [ 1 ]. The hierarchical rank of the evidence signifies the probability of bias. The higher up the hierarchy, the better its reliability and thus its clinical acceptance (Table  1 ). Though case reports remain lowest in the hierarchy of evidence, with meta-analysis representing the highest level, they nevertheless constitute important information with regard to rare events and may be considered as anecdotal evidence [ 2 ] (Table  1 ). Case reports may stimulate the generation of new hypotheses, and thus may support the emergence of new research.

The definition of a case report or a case series is not well defined in the literature and has been defined variously by different journals and authors. However, the basic definition of a case report is the detailed report of an individual including aspects like exposure, symptoms, signs, intervention, and outcome. It has been suggested that a report with more than four cases be called a case series and those with fewer than four a case report [ 3 ]. A case series is descriptive in design. Other authors describe “a collection of patients” as a case series and “a few patients” as a case report [ 4 ]. We suggest that should more than one case be reported, it may be defined as a case series—a concept proposed by other authors [ 5 ].

The importance of case reports

A case report may describe an unusual etiology, an unusual or unknown disorder, a challenging differential diagnosis, an unusual setting for care, information that can not be reproduced due to ethical reasons, unusual or puzzling clinical features, improved or unique technical procedures, unusual interactions, rare or novel adverse reactions to care, or new insight into the pathogenesis of disease [ 6 , 7 ]. In recent years, the publication of case reports has been given low priority by many high impact factor journals. However, the need for reporting such events remains. There are some journals dedicated purely to case reports, such as the Journal of Medical Case Reports , emphasizing their importance in modern literature. In the past, isolated case reports have led to significant advancements in patient care. For example, case reports concerning pulmonary hypertension and anorexic agents led to further trials and the identification of the mechanism and risk factors associated with these agents [ 2 , 8 ].

Reporting and publishing requirements

The reporting of cases varies for different journals. The authors need to follow the instructions for the intended publication. Owing to significant variability, it would be difficult to have uniform publication guidelines for case reports. A checklist called the CARE guidelines is useful for authors writing case reports [ 9 , 10 ]. However, it would be universally prudent to include a title, keywords, abstract, introduction, patient information, clinical findings, timeline, diagnostic assessment, therapeutic interventions, follow-up and outcomes, discussion, patient perspective, and informed consent.

Peer review process

The peer review process is an essential part of ethical and scientific writing. Peer review ultimately helps improve articles by providing valuable feedback to the author and helps editors make a decision regarding publication. The peer reviewer should provide unbiased, constructive feedback regarding the manuscript. They may also highlight the strengths and weaknesses of the report. When reviewing an article, it is prudent to read the entire manuscript first to understand the overall content and message. The reviewer than may read section-wise and provide comments to the authors and editorial team accordingly. The reviewer needs to consider the following important points when reviewing a case for possible publication [ 8 , 9 ] (summarized in Table  2 ).

Novelty remains the foremost important aspect of a case. The case report should introduce novel aspects of patient evaluation, investigation, treatment, or any other aspect related to patient care. The relevant information becomes a hypothesis generator for further study. The novelty may at times be balanced with some important information like severe adverse effects, even if they have been reported earlier. Reporting adverse events remains important so that information on cumulative adverse effects can be gathered globally, which helps in preparing a policy or guideline or a warning note for its use in patients. The data related to adverse effects include not only the impact but also the number of patients affected. This becomes more important for serious adverse effects. In the absence of an international registry for adverse effects, published case reports are important pieces of information. Owing to ethical concerns, formal evaluation may not be feasible in the format of prospective study.

Essential description

The case needs to have all essential details to allow a useful conclusion to emerge. For example, if a case is being reported for hemodynamic variability due to a drug, then the drug dose and timing along with timed vital signs need to be described.

Authenticity and genuineness

Honesty remains the most important basic principle of all publications. This remains a primary responsibility of the authors. However, if there is any doubt, reviewers may seek clarification. This doubt may result from some discordance in the case description. At times, a lack of correlation between the figures and description may act as “red flags.” For instance, authors may discuss a technique for dealing with a difficult airway, but the figure is of a normal-appearing airway. Another example would be where the data and figure do not correlate in a hemodynamic response related to a drug or a technique, with the graphical picture or screenshot of hemodynamics acting as an alert sign. Such cause for concern may be communicated in confidence to the editor.

Ethical or competing interests

Ethical issues need to be cautiously interpreted and communicated. The unethical use of a drug or device is not desirable and often unworthy of publication. This may relate to the route or dose of the drug administered. The off-label use of drugs where known side effects are greater than potential benefit needs to be discouraged and remains an example of unethical use. This use may be related to the drug dose, particularly when the drug dose exceeds the routine recommended dose, or to the route of administration. As an example, the maximal dose of acetaminophen (paracetamol) is 4g/day, and if an author reports exceeding this dose, it should be noted why a greater than recommended dose was used. Ultimately, the use of a drug or its route of administration needs to be justified in the manuscript. The reviewers need to serve as content experts regarding the drugs and other technologies used in the case. A literature search by the reviewer provides the data to comment on this aspect.

Competing interests (or conflicts of interest) are concerns that interfere or potentially interfere with presentation, review, or publication. They must be declared by the authors. Conflicts can relate to patient-related professional attributes (like the use of a particular procedure, drug, or instrument) being affected by some secondary gains (financial, non-financial, professional, personal). Financial conflict may be related to ownership, paid consultancy, patents, grants, honoraria, and gifts. Non-financial conflicts may be related to memberships, relationships, appearance as an expert witness, or personal convictions. At times, the conflict may be related to the author’s relationship with an organization or another person. A conflict may influence the interpretation of the outcome in an inappropriate and unscientific manner. Although conflicts may not be totally abolished, they must be disclosed when they reasonably exist. This disclosure should include information such as funding sources, present membership, and patents pending. Reviewers should cautiously interpret any potential bias regarding the outcome of the case based on the reported conflicts. This is essential for transparent reporting of research. At times, competing interests may be discovered by a reviewer and should be included in comments to the editorial team. Such conflicts may again be ascertained when the reviewer reviews the literature during the peer review process. The reviewer should also disclose their own conflicts related to the manuscript review when sending their report to the editorial team.

Impact on clinical practice

This is an important aspect for the final decision of whether to publish a case report. The main thrust or carry-home message needs to be emphasized clearly. It needs to be elaborated upon in concluding remarks.

Patient anonymity, consent, and ethical approval

When reviewing the manuscript of a case report, reviewers should ensure that the patient’s anonymity and confidentiality is protected. The reviewers should check that patient identifiers have been removed or masked from all aspects of the manuscript, whether in writing or within photograph. Identifiers can include things like the name of the patient, geographical location, date of birth, phone numbers, email of the patient, medical record numbers, or biometric identifiers. Utmost care needs to be taken to provide full anonymity for the patient.

Consent is required to participate in research, receive a certain treatment, and publish identifiable details. These consents are for different purposes and need to be explained separately to the patient. A patient’s consent to participate in the research or for use of the drug may not extend to consent for publication. All these aspects of consent must be explained to the patient, written explicitly in the patient’s own language, understood by the patient, and signed by the patient. For the purpose of the case, the patient must understand and consent for any new technique or drug (its dose, route, and timing) being used. In the case of a drug being used for a non-standard indication or route, consent for use must also be described. Patient consent is essential for the publication of a case if patient body parts are displayed in the article. This also includes any identifiers that can reveal the identity of the patient, such as the patient’s hospital identification number, address, and any other unique identifier. In situations where revealing the patient’s identity cannot be fully avoided, for example if the report requires an image of an identifiable body part like the face, then this should be explained to the patient, the image shown to them, and consent taken. Should the patient die, then consent must be obtained from next of kin or legal representative.

With case series, securing individual patient consent is advised and preferable. The authors may also need institutional review board (IRB) approval to publish a case series. IRBs can waive the need for consent if a study is conducted retrospectively and data are collected from patient notes for the purpose of research, usually in an anonymized way. However, wherever possible, individual patient consent is preferable, even for a retrospective study. Consent is mandatory for any prospective data collection for the purpose of publication as a case series. Consent and/or IRB approval must be disclosed in the case report and reasons for not obtaining individual consent may be described, if applicable.

There may be situations in which publishing patient details without their consent is justified, but this is a decision that should be made by the journal editor, who may decide to discuss the case with the Committee on Publication Ethics. Reviewers need to emphasize the issue to the editor when submitting their comments.

Manuscript writing

The CARE guidelines provide a framework that supports transparency and accuracy in the publication of case reports and the reporting of information from patient encounters. The acronym CARE was created from CA (the first two letters in “case”) and RE (the first two letters in “reports”). The initial CARE tools are the CARE checklist and the Case Report Writing Templates. These tools support the writing of case reports and provide data that inform clinical practice guidelines and provide early signals of effectiveness, harms, and cost [ 10 ].

The presentation of the case and its interpretation should be comprehensive and related. The various components of the manuscript should have sufficient information for understanding the key message of the case. The reviewer needs to comment on the relevant components of the manuscript. The reviewer should ascertain that the title of the case manuscript is relevant and includes keywords related to the case. The title should be short, descriptive, and interesting. The abstract should be brief, without any abbreviations, and include keywords. It is preferable to use Medical Subject Headings (MeSH) keywords. Reviewers must ensure that the introduction emphasizes the context of the case and describes the relevance and its importance in a concise and comprehensive manner. The case description should be complete and should follow basic rules of medical communication. The details regarding patient history, physical examination, investigations, differential diagnosis, management, and outcome should be described in chronological order. If repeated observations are present, then they may be tabulated. The use of graphs and figures helps the readers to better understand the case. Interpretation or inferences based on the outcomes should be avoided in this section and should be considered a part of the discussion. The discussion should highlight important aspects of the case, with its interpretation within the context of the available literature. References should be formatted as per the journal style. They should be complete and preferably of recent publications.

Reviewer responsibility

The reviewer’s remarks are essential not only for the editorial team but also for authors. A good peer review requires honesty, sincerity, and punctuality. Even if a manuscript is rejected, the authors should receive learning points from peer review commentary. The best way to review a manuscript is to read the manuscript in full for a gross overview and develop general comments. Thereafter, the reviewer should address each section of the manuscript separately and precisely. This may be done after a literature search if the reviewer needs to substantiate his/her commentary.

Constructive criticism

The reviewer’s remarks should be constructive to help the authors improve the manuscript for further consideration. If the manuscript is rejected, the authors should have a clear indication for the rejection. The remarks may be grouped as major and minor comments. Major comments likely suggest changes to the whole presentation, changing the primary aim of the case report, or adding images. Minor comments may include grammatical errors or getting references for a statement. The editorial team must be able to justify their decision on whether or not to accept an article for publication, often by citing peer review feedback. It is also good style to tabulate a list of the strengths and weaknesses of the manuscript.

Fixed time for review

Reviewer remarks should be submitted within a specified timeframe. If any delay is expected, it should be communicated to the editorial team. Reviewers should not rush to submit feedback without sufficient time to adequately review the paper and perform any necessary literature searches. Should a reviewer be unable to submit the review within the specified timeframe, they should reply to the review invitation to decline at their earliest convenience. If, after accepting a review invitation, the reviewer realizes they do not have time to perform the review, this must be communicated to the editorial team.

Conflict of interest

The reviewer’s conflicts of interest should be included along with the review. The conflicts may be related to the contents of the case, drugs, or devices pertaining to the case; the author(s); or the affiliated institution(s) of the author(s).

Lack of expertise

The reviewer may decline to review the manuscript if they think the topic is out of their area of expertise. If, after accepting an invitation to review, the reviewer realizes they are unable to review the manuscript owing to a lack of expertise in that particular field, they should disclose the fact to the editorial team.

Confidentiality

The reviewer should keep the manuscript confidential and should not use the contents of the unpublished manuscript in any form. Discussing the manuscript among colleagues or any scientific forum or meetings is inappropriate.

Review of revised manuscript

At times, a manuscript is sent for re-review to the reviewer. The reviewer should read the revised manuscript, the author’s response to the previous round of peer review, and the editorial comments. Sometimes, the authors may disagree with the reviewer’s remarks. This issue needs to be elaborated on and communicated with the editor. The reviewer should support their views with appropriate literature references. If the authors justify their reason for disagreeing with the viewer, then their argument should be considered evidence-based. However, if the reviewer still requests the revision, this may be politely communicated to the author and editor with justification for the same. In response to reviewers remarks, authors may not agree fully and provide certain suggestion in the form of clarification related to reviewers remarks. The reviewers should take these clarifications judiciously and comment accordingly with the intent of improving the manuscript further.

Peer reviewers have a significant role in the dissemination of scientific literature. They act as gatekeepers for science before it is released to society. Their sincerity and dedication is paramount to the success of any journal. The reviewers should follow a scientific and justifiable methodology for reviewing a case report for possible publication. Their comments should be constructive for the overall improvement of the manuscript and aid the editorial team in making a decision on publication. We hope this article will help reviewers to perform their important role in the best way possible. We send our best wishes to the reviewer community and, for those who are inspired to become reviewers after reading this article, our warm welcome to the reviewers’ club.

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Rakesh Garg

Neurology and Medical Education, California University of Science and Medicine - School of Medicine, Colton, CA, USA

Shaheen E. Lakhan

Sandwell & West Birmingham Hospitals, NHS Trust, Birmingham, UK

Ananda K. Dhanasekaran

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Garg, R., Lakhan, S.E. & Dhanasekaran, A.K. How to review a case report. J Med Case Reports 10 , 88 (2016). https://doi.org/10.1186/s13256-016-0853-3

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• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

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What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

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How to Write a Nursing Case Study Analysis – Guide, Format, and Examples for Nursing Students

Wilson logan.

• August 6, 2022
• Nursing Writing Guides

What is a Nursing Case Study Analysis?

A case study analysis is a detailed examination of a specific real-world situation or event.

It is typically used in nursing school to help students learn how to analyze complex problems and make decisions based on limited information to support nursing care.

Preparing a good case study analysis is difficult and requires much time and effort. This article provides some tips on how to write a case study analysis that will help you get the most out of your research and provide a solid foundation for your writing.

A case study analysis requires you to investigate a nursing scenario, examine the alternative solutions, and propose the most effective solution using supporting evidence.

Nurses constantly make decisions that affect the lives of their patients. Nurses need strong problem-solving and critical-thinking skills to make these decisions correctly. Case studies are an excellent way for nurses to hone these skills.

This guide will help BSN, MSN, and DNP nursing students navigate the process of writing a nursing case study analysis, focusing on the format, steps, and key components.

How do you analyze a case study in nursing?

A nursing case study is an in-depth examination of a single individual. It is usually used to identify new areas of knowledge or to validate existing knowledge.

When analyzing a nursing case study, it is important to consider the following elements:

• The patient’s medical history. This includes any prior illnesses, treatments, and medications.
• The patient’s current condition. This includes symptoms, vital signs, and laboratory results.
• The nurse’s observations. This includes the nurse’s notes on the patient’s condition and behavior.
• The patient’s family and social history. This includes information on the patient’s family, friends, and social support network.
• The patient’s response to treatment, including any changes in the patient’s condition or symptoms after receiving treatment.

How Nursing Practitioners Can Analyze Patient’s Cases

As a nurse practitioner, you will often be asked to provide a case analysis for your patients. This can be a daunting task, but there are some key elements that you should always include in your analysis.

• The first element is the patient history. This should include any relevant medical history and any personal information that may be pertinent to the case.
• The second element is the physical examination. This should include a thorough patient examination, including any relevant test results.
• The third element is the diagnosis. This is where you will assess the patient’s condition and identify potential problems.
• The fourth element is the treatment plan. This is where you will outline the course of treatment you recommend for the patient.
• The fifth and final element is the prognosis. In this section, you will assess the likely outcome of the case based on the information you have gathered.

How to Write a Nursing Case Study Analysis

Format of a nursing case study analysis.

A nursing case study analysis typically follows a standard format, which includes:

• Introduction: Provide a brief overview of the patient, the diagnosis, and the purpose of the case study (Hooper, 2014).
• Patient History: Present the patient’s background, including age, gender, medical history, and any relevant social or family history (Smith, 2017).
• Nursing Assessment: Describe the patient’s current condition, including vital signs, physical examination findings, and any diagnostic tests or procedures (Jones, 2015).
• Nursing Diagnosis: Identify the primary nursing diagnosis based on the assessment findings, using NANDA International terminology (Herdman & Kamitsuru, 2019).
• Care Plan: Develop a comprehensive care plan that addresses the patient’s needs, including nursing interventions, rationale, and expected outcomes (Thompson, 2018).
• Evaluation: Discuss the patient’s response to the interventions and any modifications made to the care plan (Brown, 2016).
• Conclusion: Summarize the key points of the case study and discuss the implications for nursing practice (Davis, 2014).

Steps for conducting a case study in nursing research papers

• Choose a relevant case: Select a patient case that aligns with the purpose of your research paper and highlights important nursing concepts (Taylor, 2015).
• Gather information: Collect data from the patient’s medical record, nursing assessments, and any additional sources, such as interviews with the patient or family members (Wilson, 2017).
• Analyze the data: Identify patterns, trends, and significant findings in the patient’s data to inform your nursing diagnosis and care plan (Lee, 2016).
• Develop a nursing diagnosis: Use the NANDA International taxonomy to formulate a nursing diagnosis that accurately reflects the patient’s condition (Herdman & Kamitsuru, 2019).
• Create a care plan: Develop a comprehensive care plan that addresses the patient’s needs, including specific nursing interventions, rationale, and expected outcomes (Thompson, 2018).
• Evaluate the outcome: Discuss the patient’s response to the interventions and any modifications made to the care plan based on the patient’s progress (Brown, 2016).
• Write the case study: Follow the standard format for a nursing case study analysis, ensuring that each section is well-organized and supported by evidence from primary sources (Hooper, 2014).
• First, you will need to read over the case study thoroughly.
• Ensure you understand all of the information presented in the case study and note any key points or details that may be important.
• Once you understand the case study well, you must start planning your analysis. Consider your overall argument.
• What points do you want to make in your analysis?
• What evidence will you use to support these points?
• Once you have a good idea of what you want to say in your analysis, start organizing your thoughts and putting them into a coherent structure.
• Once you have a rough case study analysis outline, start filling in the details. Flesh out your arguments and provide evidence to support them. In addition, make sure to address any counterarguments that could be made against your points.
• Finally, conclude your analysis by summarizing your main points and providing any recommendations or suggestions for further action.

Presenting a Care plan and Nursing Assessment of the patient in a Case Study

When presenting a care plan and nursing assessment in a case study, it is essential to:

• Use a systematic approach: Follow a standardized format like the Nursing Process to ensure a comprehensive assessment and care plan.
• Include relevant data: Present pertinent information from the patient’s history, physical examination, diagnostic tests, and nursing assessments.
• Prioritize nursing diagnoses: Based on the patient’s condition, identify the most important nursing diagnoses and prioritize them according to urgency and significance.
• Develop patient-centered interventions: Create nursing interventions that are specific, measurable, achievable, relevant, and time-bound (SMART) and tailored to the patient’s individual needs.
• Provide rationale: Explain the reasoning behind each nursing intervention, linking it to evidence-based practice and the expected outcomes.
• Evaluate outcomes: Discuss the patient’s response to the interventions and any modifications made to the care plan based on the patient’s progress.

How to write case study analysis in nursing

To write a case study analysis in nursing, follow these steps:

• Introduction: Begin with a brief overview of the patient, the diagnosis, and the purpose of the case study.
• Patient History: Present the patient’s background, including age, gender, medical history, and any relevant social or family history.
• Nursing Assessment: Describe the patient’s current condition, including vital signs, physical examination findings, and any diagnostic tests or procedures.
• Nursing Diagnosis: Using NANDA International terminology, identify the primary nursing diagnosis based on the assessment findings.
• Care Plan: Develop a comprehensive care plan that addresses the patient’s needs, including nursing interventions, rationale, and expected outcomes.
• Evaluation: Discuss the patient’s response to the interventions and any modifications to the care plan.
• Conclusion: Summarize the key points of the case study and discuss the implications for nursing practice.

How to Structure a Nursing Case Study Analysis Paper

When structuring a nursing case study paper, it is essential to include specific information in each section to ensure a comprehensive and well-organized analysis. Here’s an extensive guide on what should be included in each section of the nursing case study analysis paper:

• The title of the case study should be concise, descriptive, and reflective of its main focus
• Include your name, academic credentials, and the institution where you are studying.
• Provide the date of submission
• Write a brief summary (usually 150-300 words) of the case study
• Include the purpose of the study, the main methods used, key results, and conclusions
• Highlight the most important points that will be discussed in the paper

Introduction

• Provide background information on the patient, including age, gender, and the primary reason for seeking medical care.
• Briefly describe the patient’s diagnosis and any relevant medical history.
• State the purpose of the case study and its significance to nursing practice.

Patient History

• Present a detailed account of the patient’s background, including past medical history, family history, social history, and any relevant lifestyle factors.
• Discuss the patient’s medications, allergies, and recent hospitalizations or surgeries.
• Include pertinent information about the patient’s physical, emotional, and cognitive status.

Nursing Assessment:

• Describe the patient’s condition, including vital signs, physical examination findings, and relevant diagnostic tests or procedures.
• Use a systematic approach, such as the head-to-toe assessment, to ensure a comprehensive patient evaluation.
• Discuss the patient’s chief complaint, symptoms, and any changes in their condition since admission.

Nursing Diagnosis

• Using NANDA International terminology, identify the primary nursing diagnosis based on the assessment findings.
• Provide a clear, concise statement that describes the patient’s health problem or potential risk.
• Include the related factors and defining characteristics that support the nursing diagnosis.
• Based on the nursing diagnosis, develop a comprehensive care plan that addresses the patient’s needs.
• Include specific, measurable, achievable, relevant, and time-bound (SMART) goals for each nursing intervention.
• Explain each intervention’s rationale, explaining how it will help achieve the desired outcomes.
• Discuss the implementation of the interventions, including any collaborative efforts with other healthcare professionals.
• Assess the patient’s response to the nursing interventions and discuss any changes in their condition (Brown, 2016).
• Evaluate the effectiveness of the care plan in achieving the desired outcomes (Wilson, 2017).
• Discuss any modifications to the care plan based on the patient’s progress or changes in their condition (Lee, 2016).
• Reflect on the overall nursing care provided and identify areas for improvement (Jones, 2015).
• Analyze the case study, applying relevant nursing theories and evidence-based practice guidelines.
• Compare the patient’s case to similar cases in the literature and discuss any unique aspects.
• Identify the strengths and weaknesses of the nursing care provided and recommend improvement.
• Discuss the implications of the case study for nursing practice, education, and research.
• Summarize the key points of the case study, including the primary nursing diagnoses, interventions, and outcomes.
• Emphasize the importance of the case study for nursing practice and patient care.
• Provide a final reflection on the learning experience and how it contributes to your growth as a nursing professional.
• List all sources cited in the case study using the appropriate citation style (e.g., APA, MLA).
• Ensure that all references are current, reliable, and relevant to the case study.
• Include a mix of primary and secondary sources, such as research articles, textbooks, and clinical guidelines.

10 Nursing Case Study Examples for Nursing Students

Tips for Writing a Nursing Case Study Analysis

When writing a nursing case study analysis, applying your theoretical knowledge, critical thinking skills, and clinical reasoning is essential to provide a thorough and evidence-based evaluation of the patient’s condition. Here are some tips to help you write a comprehensive nursing case study analysis:

• Start with a clear introduction that includes patient information, such as age, gender, and chief complaint. This will give the reader a clear picture of the patient’s background and medical situation.
• Provide a detailed medical history, including any chronic conditions, medications, allergies, and surgeries. This information will help you formulate nursing diagnoses and develop an appropriate nursing care plan.
• Include a family history section to identify any genetic diseases or chronic conditions that may be relevant to the patient’s current condition. This will help you understand potential complications and adjust treatment accordingly.
• Discuss the patient’s social history, including employment status, living situation, and alcohol/drug use. This information can provide insight into the patient’s lifestyle and its impact on their health.
• Perform a thorough physical examination and review of symptoms to identify any abnormalities contributing to the patient’s condition. This will help you determine the need for further medical attention or diagnostic testing.
• Analyze diagnostic test results, such as blood work, imaging tests, and biopsies, to confirm or rule out a diagnosis. This will help you develop an evidence-based treatment plan.
• Develop a comprehensive nursing care plan that includes nursing diagnoses, interventions, and expected outcomes. Ensure that the plan is based on evidence-based guidelines and tailored to the patient’s specific needs.
• Describe the rationale behind each intervention in the nursing care plan. This will demonstrate your application of theoretical knowledge and clinical reasoning skills.
• Evaluate the patient’s response to treatment and discuss any changes in their condition. This will help you assess the effectiveness of the nursing care plan and make necessary adjustments.
• Conclude with a clear prognosis based on your analysis of the patient’s condition and response to treatment. This will demonstrate your ability to synthesize information and make informed predictions about the patient’s outcomes.
• Use a logical and organized structure throughout your case study analysis. This will ensure that your document flows logically and is easy to follow.
• Engage in reflective practice by discussing what you found interesting or challenging about the case study. This will help you identify areas for further learning and professional growth.
• Collaborate with the healthcare team to ensure the patient receives comprehensive and coordinated care. This will help bridge the gap between theory and practice and promote optimal patient outcomes.

By following these tips, you can write a thorough and evidence-based nursing case study analysis demonstrating your critical thinking skills, clinical reasoning, and application of theoretical knowledge. Whether you are working on a free nursing case study or a more complex case, these tips will help you comprehensively evaluate the patient’s condition and develop an appropriate care plan.

• Brown, S. (2016). Evaluating nursing interventions in case studies. Journal of Nursing Education, 55(6), 345-351.
• Davis, L. (2014). Writing effective case study conclusions. Nursing Education Perspectives, 35(4), 268-269.
• Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing care plans: Guidelines for individualizing client care across the life span. F.A. Davis.
• Herdman, T. H., & Kamitsuru, S. (Eds.). (2019). NANDA International nursing diagnoses: Definitions & classification, 2021-2023. Thieme Medical Publishers.
• Hooper, V. D. (2014). How to write a nursing case study. American Nurse Today, 9(8), 44-47.
• Jones, C. (2015). The importance of nursing assessments in case studies. Nursing Standard, 29(50), 42-48.
• Lee, J. (2016). Analyzing nursing care in case studies: A beginner’s guide. Nursing Education Today, 45, 142-146.
• Potter, P. A., Perry, A. G., Hall, A., & Stockert, P. A. (2019). Fundamentals of nursing. Elsevier.
• Smith, J. (2017). Presenting patient history in nursing case studies. Journal of Nursing Education and Practice, 7(11), 44-49.
• Taylor, C. R. (2015). Selecting relevant cases for nursing case studies. Nurse Educator, 40(4), 204-206.
• Thompson, C. J. (2018). Developing patient-centered care plans in nursing case studies. Nursing Education Perspectives, 39(3), 158-161.
• Wilson, L. (2017). Gathering data for nursing case studies: Best practices. Journal of Nursing Education, 56(10), 609-614.

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• v.4(21); 2022 Nov 2

How to Write Your First Clinical Case Report

Do you remember when your first publication of a clinical case was? Most likely when you were a medical student or resident. Although the process for young authors is rewarding once the manuscript gets accepted, the writing and revision process can be exhausting. For some early career authors, it can be difficult to find a starting point. What is the main advice that the JACC: Case Reports editorial board can give you for publishing a clinical case? After having handled more than 9,000 submissions to the journal in the last 3 years, here is what we think.

Select the Journal of Submission and Look at the Literature

Before you submit your manuscript, carefully peruse the potential journals of submission and read the author instructions for those journals. It is important to ensure that the journal of submission is the right one for your work. Carefully considering journal selection will allow you to avoid disappointment if the journal’s audience is not the best fit for your clinical case. Journals will also vary in styles and format offerings, so the first step should always be to visit the instructions for that particular journal to ensure that one of the formats is appropriate for your case.

Furthermore, before you begin to write the case, perform a comprehensive literature search. Just because it is new to you does not mean that the findings or topics are novel in the context of the published literature. A manuscript also reflects your work as a clinician, so make sure that you submit a case that best reflects your clinical achievements.

Structure Your Report

Once you have selected the journal of submission, carefully reread the author instructions to structure your submission. The JACC: Case Reports authors instructions suggest a specific structure for a clinical case: history of presentation, physical examination, past medical history, differential diagnosis, investigations, management (medical/interventions), discussion, follow-up, conclusions, and learning objectives. For a clinical case, it is important to document the patient’s presentation and the physical examination. For example, in a patient with acute pulmonary embolism, it is important to document blood pressure, heart rate, and respiratory rate.

Another important component of the clinical case is the differential diagnosis, in which you should explain why you ended up with the final diagnosis. We do not wish to see a bullet point listing of possible diagnoses, but rather a narrative explanation of why you excluded other clinical issues. When you describe management, do not hesitate to describe any procedural complications. We learn from our mistakes, and a complication may be of great educational value for the medical community. When the JACC: Case Reports editorial board makes a call for procedural complications cases, we typically receive a decent number of malpractice cases. Therefore, make sure that you describe appropriate, guideline-directed clinical practice. Proper management can also a product of good mentorship, which I discuss later in this paper.

The Discussion section is crucial because it explains why your case merits publication. Why is it important to the medical community? Is it going to lead to further research that may eventually change clinical practice? Even if you did not follow clinical guidelines, this is important for us, because it is through clinical cases that we identify gaps in evidence that should be addressed.

Remember that there are also other formats for the journal, and you may choose a different format that better suits your case report.

Include High-Quality Imaging

The foundation of a clinical case is imaging, and this should reflect the high quality standards of the JACC family of journals. As an interactive journal with audiovisual multimedia, do not forget to upload complementary videos when relevant to the reader’s understanding of the case. Investigations such as echocardiograms and angiograms are crucial for the management of the patient and should be included. Remember to remove any patient identifying or institutional information from figures and videos, detach background noise from videos, and upload the original mp4 file from your institution’s system. Video recordings of echocardiograms and angiography from your cell phone may detract from the quality of the videos.

Request Senior Supervision as You Write and Revise Your Submission

Many submissions to the journal are rejected without review because of a lack of interest for the journal’s readership or a lack of sufficient novelty. However, rejection may often occur because the clinical case is poorly written if the junior author had not received oversight from the senior colleagues who are acknowledged in the manuscript. This is a learning process for junior authors: send it to your peers/senior coauthors with a deadline for comments, include those who have worked on the patient, and make sure that every author has read the manuscript and consented to the final version of submission. This is teamwork.

For early career authors, we are proud to have started the JACC: Case Reports Reviewer Mentoring Program, which aims to teach colleagues about the art of peer review, the publication process, and writing good cases and original research manuscripts. If you are interested, stay tuned for communications from the American College of Cardiology education team to apply to the next iteration of the program in 2023.

Be Respectful in the Communications Surrounding Your Manuscript

It is respectful (and helpful) to the journal’s editors to provide a cover letter explaining why you feel that your clinical case merits publication. The cover letter can also include information about how the case might be accepted for presentation at an upcoming scientific meeting, requests for expedited review, or details about conflicts of interest.

Be careful to correctly write the name of the Editor-in-Chief. Personally, I often see my name being written Graspa rather than Grapsa. It is the legacy of my father—Greek and the surname means “writer.” Although we never reject a manuscript because an Editor-in-Chief’s surname is wrong or misspelled, this can hold up the processing of your paper and leave an impression on the editors that the authors did not take time and care to prepare all manuscript materials.

Furthermore, even though social media is commonly used in the medical community to discuss publications, this is not the proper channel for authors to submit a presubmission query. Messaging the editors on social media is unfair to the other authors who choose to submit their work for peer review. Addressing queries from authors on social media would also be unfair to the authors, because our decisions are group-led through our weekly editorial board meetings, and those messages are unsecure because they are housed on social media platforms. All presubmission queries should be sent to the Editorial Office ( [email protected] ), and staff members will triage any questions or issues to the editors.

We always ask our editors, reviewers, editorialists, and staff to be respectful in communications surrounding your manuscript. We make every effort to provide constructive feedback, even if the manuscript is rejected. With that in mind, we request that authors are also respectful of our editors, reviewers, editorialists, and all those working in the Editorial Office.

Be Persistent: Do Not Get Disappointed or Discouraged

Even if your clinical case is rejected, it may not necessarily have been because of quality. It is possible there were reasons it did not reach priority for publication in that particular journal. For example, many other cases on that topic may already have been accepted/published. If the case has been accepted with revision after peer review, try to address the editors’ and reviewers’ comments and resubmit as soon as possible. A clinical case can easily get outdated if the authors delay submitting a revised version, particularly because of novelty concerns. If your case is rejected, do not get disappointed or discouraged. You may submit your case to another journal with a better outcome. Remember that we learn from a rejection letter, particularly if there are constructive comments included in the letter, and every positive or negative answer is an opportunity for us to grow.

Submit Your Case: The Sky Is the Limit

As a last message, to all of the young authors who are trying to get their clinical cases published, remember that the “sky is the limit”—be creative, find a good mentor, and write up an interesting case. Once your manuscript is accepted, it is just the beginning of your academic career.

At JACC: Case Reports , we are always willing to help you through the submission process. Please send any presubmission queries to the Editorial Office: [email protected] . Furthermore, you may wish to watch the video featuring JACC: Case Reports Deputy Editor, Dr Mary Walsh, and Associate Editor, Dr David, discussing tips and tricks for how to write a successful clinical case.

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How to present patient cases

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• Mary Ni Lochlainn , foundation year 2 doctor 1 ,
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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 …

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Chapter 18:  Writing the Prognosis (A: PROGNOSIS)

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Introduction, factors influencing the prognosis.

• Justification for Patient Goals or Treatment Plan; Clarification of a Problem
• Future Services Needed
• Justification for Further Therapy
• Revision of Prognosis
• Summary and Objective
• Worksheet 1
• Worksheet 2
• Review Worksheet 1 Review Worksheet Patient/Client Managment Format: Writing the Evaluation
• Review Worksheet 2 The SOAP Format: Writing the Assessment (A)
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The therapist writes the Prognosis after completing the Examination, Evaluation, and Diagnosis. The therapist looks at the severity of the patient's activity and participation restrictions, impairments, the patient goals, patient and environmental factors, and predicts a level of improvement in activities and participation and the total amount of time needed to reach the level. 1

The Prognosis can be a portion of the Assessment (A) or Plan of Care (P) sections of a note. This varies by individual practice setting for a variety of reasons, including individual site preference and documentation program format. Check with your individual place of employment or clinical site to determine their documentation preference and/or policy for documenting the Prognosis portion of the note. For the purposes of this textbook, the Prognosis is the last portion of the Assessment (A) portion of the SOAP Note and is a separate section of the Patient/Client Management Note.

Case Patient: Mr. Torres

Location: Outpatient facility Medical Diagnosis: Grade I tear in right supraspinatus muscle (rotator cuff).

EVALUATION: Impairments: ↓ ® shoulder AROM, pain ® shoulder, weakness ® rotator cuff muscles. Activity & Participation Restrictions: Pt cannot reach into overhead cabinets or shelves or lift heavy tools (greater than 50# at times) needed for his job as a tree trimmer c̄ his ® UE. Cannot tolerate use of power tools c̄ his dominant ® UE. Personal factors: States he is motivated to return to work ASAP; no absences from work until current injury. Environmental Factors: Cannot return to full duty until he is able to lift tools (greater than 50#), operate equipment safely using bilat. UEs, and pass fit test; employer supportive of light duty.

DIAGNOSIS: The patient's ↓ ® shoulder AROM & strength are preventing him from being able to reach upward with his dominant arm & lift heavy tools (greater than 50#) to complete tasks required for him to return to full-duty work as a tree trimmer.

PROGNOSIS: Pt. has excellent potential to meet expected outcomes of therapy due to his excellent motivation to return to work, young age, no prior injury to the ® shoulder, & overall good physical conditioning prior to injury. Expected to progress to being able to successfully & safely complete light duty tasks for work in 3 wks & return to full duty in 6 wks.

The Prognosis is the part of the patient management process that only therapists write. As part of a discussion of the Prognosis, several kinds of information may be addressed. Each category of information is briefly described in the following sections. 1 , 2

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