How do I write a case report on a complex medicine inpatient case?

How to Write a Case Report on a Complex Medicine Inpatient Case

Writing a comprehensive case report on a complex medicine inpatient case requires a structured approach that highlights the unique aspects of the case while providing valuable clinical insights for readers. Follow this systematic framework to create an effective case report that contributes to medical knowledge.

Selecting an Appropriate Case

• Choose a case that provides clear "learning points" - not just focusing on rarity but on educational value, novel presentations, unusual disease associations, or innovative management approaches 1.
• Ensure the case advances understanding of a disorder, increases clinical skill, or suggests useful research directions 2.
• Consider cases that demonstrate diagnostic challenges, unexpected outcomes, or successful management of complex multimorbidity 3.

Structuring Your Case Report

Title

• Create a clear, concise title that accurately reflects the key aspect of the case 2.
• Include relevant clinical features or the main teaching point to attract appropriate readers 4.

Abstract

• Write a structured abstract summarizing the four main sections of your report: introduction, case presentation, discussion, and conclusion 4.
• Keep it concise (250 words or less) while capturing the essential elements and key learning points 2.

Introduction

• Provide context by explaining why the case merits reporting 4.
• Include a focused literature review that establishes the uniqueness or significance of your case 4.
• Clearly state the objective of presenting this particular case 2.

Case Presentation

• Present the case chronologically with sufficient detail for readers to form their own conclusions 4.

• Document the following essential elements:

  • Detailed medical history including all known diagnoses and conditions 3.
  • Comprehensive medication history (prescription, OTC, supplements) with start dates and any recent changes 3.
  • Relevant physical examination findings and vital signs 3.
  • Laboratory and diagnostic test results, highlighting abnormal findings 3.
  • Clinical course during hospitalization, including interventions and patient's response 3.
  • Assessment of disease burden and its effect on patient's quality of life 3.

• For complex multimorbidity cases, include:

  • Interaction assessment between diseases and treatments 3.
  • Medication review evaluating risk-benefit of each drug, possible interactions, and adherence 3.
  • Functional and physiological status assessment 3.

Discussion

• This is the most important section of your case report 4.
• Compare and contrast your case with published literature 4.
• Evaluate the case for accuracy, validity, and uniqueness 4.
• Explain the rationale behind clinical decisions, especially when managing multiple chronic conditions 3.
• Discuss how you prioritized interventions based on potential impact on morbidity, mortality, and quality of life 3.
• Address any diagnostic or therapeutic challenges encountered 3.
• Highlight the strengths and limitations of your approach 3.

Conclusion

• Provide a brief conclusion with evidence-based recommendations 4.
• Emphasize the key learning points and their applicability to clinical practice 2.
• Avoid speculation not supported by the case or literature 2.

Best Practices for Effective Case Reports

• Be concise - include only pertinent information and avoid excessive detail that obscures the essence of the report 2.

• Use tables and figures judiciously to present complex data in an easily interpretable format 2.

• Include appropriate documentation with essential citations that you have personally reviewed 2.

• For complex cases with multimorbidity, clearly document:

  • How you reconciled multiple medical problems and treatments 3.
  • Your decision-making process for prioritizing interventions 3.
  • How you engaged the patient in shared decision-making 3.
  • Your approach to medication management, including deprescribing decisions 3.

• Consider including a domains-based assessment covering:

  • Medical management 3
  • Physical functioning 3
  • Mental and emotional aspects 3
  • Social and environmental factors 3

Publication Considerations

• Follow the "Uniform Requirements for Manuscripts to Biomedical Journals" as the basis for formatting 5.
• Consider using established reporting guidelines such as CARE (CAse REport) or Surgical CAse REport checklists 3.
• Target journals appropriate for your case's specialty area and learning points 5.
• Be prepared to respond effectively to reviewer comments 1.

Common Pitfalls to Avoid

• Including irrelevant details that distract from the main teaching points 2.
• Failing to provide adequate literature context for the case 4.
• Overgeneralizing conclusions beyond what the single case can support 2.
• Neglecting to obtain proper patient consent for publication 3.
• Inadequate protection of patient confidentiality and identifiable information 3.

By following this structured approach, you can create a compelling case report that effectively communicates the unique aspects of your complex inpatient case while providing valuable insights for clinical practice.