Feature

Case Reports - Your Next (First) Writing Opportunity Awaits

Tosha Harris, DNP APRN NNP-BC 

Some of you may have seen my postings in the various special interest groups asking for volunteers to submit to our bimonthly newsletter. Some of you may have been tempted but shied away because (and I get it) there aren't enough hours in the day to take care of the hundred other items on your to-do list, and writing a newsletter article is not a priority item. But some of you (and I know you're out there) have considered it, but then the negative thoughts and self-doubt convinced you otherwise. Don't listen to the negativity! It's not as hard as it seems. By now, you're probably saying, "I have nothing to write about"; sure you do. Every day you provide care, educate, advocate, mentor, collaborate, and affect change is a writing opportunity.

This month, we will explore case studies and how to write your own. Case reports, case studies, or clinical vignettes are all terms for the detailed report of an individual patient's diagnosis, treatment, and follow-up. Case reports have long been used as an educational tool in teaching physicians and advanced practice providers and for sharing educational experiences. Clinical practice generates clinical questions, and answering these questions requires performing a thorough and effective search of the medical literature to uncover the best current evidence to answer these questions. Writing a case report provides experience searching the literature and writing (Florek & Dellavalle, 2016). You will come across a compelling and perplexing patient case at some point in your career. Writing a case report is an excellent opportunity to develop your writing skills, disseminate your findings, and contribute to the medical literature.

Publishable case reports can include but are not limited to cases that:

• Describe uncommon or new diagnostic features of a disease
• Describe an unexpected association between diseases or symptoms
• Explain new findings on the pathogenesis or adverse effects of a disease
• Describe unique or rare qualities of a disease
• Describe a new surgical procedure
• Describe life-threatening adverse events
• Report medical or medication safety
• Use technology to improve patient outcomes
• Use life-saving techniques that have not previously been documented
• Describe the effect of drugs in pregnancy and lactation
• Review a unique job description of a health care professional that improves patient care (Cohen, 2006; Oyibo, 2019). 

In 2013, the CARE (CAse REports) guidelines were published to assist authors in systematically writing case reports. The accompanying 13-item checklist helps authors be precise, complete, and transparent when publishing case reports (Florek & Dellavalle, 2016). Also, many journals may provide authors with specific instructions for publication, including acceptance criteria, content and formatting criteria, and suggestions on case reports that merit publication (Rison, 2013). Authors seeking publication of their case reports are encouraged to become familiar with the CARE guidelines and journal-specific publication requirements before submitting the manuscript.

Case reports are typically 1500-2500 words and include 20-30 references. The report should include an abstract and four main sections of text: introduction, case presentation, discussion, and conclusion (Cohen, 2006). The format of these sections will depend on the criteria for publication set forth by the journal.

Abstract. The abstract of the case reports gives a 100–250-word synopsis of the case report. The abstract should be written to include the same four sections of the main text and should be informative yet concise. Abstracts are retrieved through electronic databases with links provided to the full-text manuscript. Therefore, the abstract should be written to pique the interest of the literature searcher. It is often easier to compose the abstract after the main body of the text has been completed (Cohen, 2006; Oyibo, 2019).

Introduction. The case report introduction should typically consist of no more than three paragraphs; therefore, authors should be mindful to avoid verbosity but use selective wording to attract the researcher's attention. The introduction should describe the subject of the case report and include sufficient background information to clarify the topic, state the purpose or objective of the report, provide definitions of pertinent terminology, and expound on why the presentation of the subject matter is essential (Cohen, 2006).

The introduction also includes a comprehensive literature review that validates the importance of the case report. The literature review should list the databases searched, the search strategy used to explore the databases, the dates the databases were searched, the languages searched, and the search terms used to search the databases (Cohen, 2006). Subject matter novelty can significantly influence literature search results. If few citations are found to support the subject matter, each one should be chronologically listed in the reference list. However, if many sources are discovered, authors are encouraged to cite seminal, historical, and pertinent references (Cohen, 2006). The reference list of review articles and meta-analyses can be rich sources of references; authors should review these lists to maximize their literature search findings. The final component of the introduction is a brief description of the patient's case, which serves as a transition to the case presentation section of the case report.

Case Presentation. The case presentation is one of the most critical sections of the case report and should contain only information that is pertinent to the case. Details within the section should be written in chronological order and expounds on the patient demographics and history, laboratory and diagnostic data, and medication history.
Specific patient demographics, such as age, height, weight, sex, and race, must be included. Authors should refrain from adding details that could lead to patient identification; therefore, the patient's initials, date of birth, and other potential identifiers such as date of admission, should be excluded (Cohen, 2006; Rison, 2013).

The patient's chief complaint, history of present illness, family and social history, symptoms, relevant laboratory and diagnostic data, including a timeline in which they were obtained, and a brief report of the results should be included in a narrative format. Laboratory and diagnostic results that support the case report and rule out differential diagnoses and any treatments or interventions should be included (Cohen, 2006; Rison, 2013).
The patient's medication history should include the medication's name (brand or generic), manufacturer, strength, dosage, route, and dates of administration and discontinuation. A drug allergy history, if identified, should be reported and include the name of the drug, the date of the reaction, and the type of allergic reaction. If available, serum drug levels should be listed and include the time of collection, their relationship to medication dosage (random, peak, trough levels), the delineation between total and free levels, and reference ranges should always be provided (Cohen, 2006).

Discussion. According to Cohen (2006), the discussion section of the case report is the most important. Within this section, the author will convey what lessons were learned from the case by:

• Explaining any similarities or differences between the report and the published literature
• Listing the limitations of the report and describing the significance of each limitation
• Establishing temporal and casual relationships
• Summarizing the essential features of the report
• Justifying the uniqueness of the case
• Drawing conclusions

Conclusion. The case report's conclusion, often one paragraph in length, summarizes the most critical findings from the case. The author may use this section to provide evidence-based recommendations and future opportunities for research and describe the results that apply to one's practice (Cohen, 2006).

Writing for publication is an intimidating process, even for experienced writers. The task can be so daunting that it can prevent you from trying; therefore, I would encourage you to test the waters on a smaller scale. Submitting a case report to the NANN E-News newsletter provides that same opportunity.

Dr. Bobby Bellflower is a Professor and Director of the Doctor of Nursing Practice program at the University of Tennessee Health Science Center College of Nursing in Memphis, TN, and Chair of the National Association of Neonatal Nurse Practitioners (NANNP) Council. She created the following outline to assist neonatal clinicians in developing a case report; with her permission, I share it with our readers. Not all the components of a publishable case report are included within the outline; if authors wish to publish in peer-reviewed journals, they should follow the CARE guidelines mentioned above.

1. Introduction
2. Presentation of specific patient case
   1. Maternal and prenatal history
   2. Labor and delivery history
   3. Immediate postpartum course
   4. Signs and symptoms of the disease process
   5. Lab and diagnostic evaluation of signs of disease
   6. Diagnosis (including differential diagnosis)
   7. Specific treatment for the patient
   8. Response to treatment
   9. Patient outcome (death, morbidity, follow-up care needed, etc.)
   10. Family involvement
3. Discussion of the disease process
   1. Definition
   2. Historical aspects (naming, discovery, early literature)
   3. Signs and symptoms
   4. Diagnostic evaluation, including labs
   5. Treatment options and likely outcomes of the different options
   6. Expected outcome based on age, gender, family history, etc.
   7. Follow-up care needed
   8. Effect on health as an adult
4. Relationship of specific case presentation to academic discussion of the disease process
   1. Did the case presented follow the expected course according to the discussion of the disease process?
   2. Did the expected outcome occur?
   3. Did the multidisciplinary team follow accepted guidelines in the treatment regimen?
   4. Did the team develop new treatment regimens, successful or unsuccessful?
   5. Would the team do anything differently?

There are a few things I would like you to remember regarding your writing abilities when in doubt. First, what you have to say is essential. Not all neonatal nurses and APRNs have access to medical libraries or unit educators. For those, the information provided on our website and NANN Neonatal News is the extent of their evidence-based education. And some simply love to learn. Therefore, we must contribute to building our professional knowledge base. Secondly, not every neonatal nurse or APRN works in a high acuity Level IV NICU. There are cases you have seen and experiences you have had that some have not and may never experience. We must share the knowledge we gain with others so that all our patients and families may benefit from our shared learning. Lastly, please remember that the articles and research studies you read are NOT first drafts! They are the product of months, sometimes years, of edits and revisions, frustrations, and maybe even a few tears. And so, write with the understanding that your manuscript will undergo editing. You don't have to write perfectly. Just write something.

References

CARE Case Report Guidelines. (n.d.). CARE Case Report Guidelines. Retrieved July 15, 2022, from https://www.care-statement.org

Cohen, H. (2006). How to write a patient case report. American Journal of Health-System Pharmacy, 63(19), 1888–1892. https://doi.org/10.2146/ajhp060182

Florek, A. G., & Dellavalle, R. P. (2016). Case reports in medical education: A platform for training medical students, residents, and fellows in scientific writing and critical thinking. Journal of Medical Case Reports, 10(1), 86, s13256-016-0851–0855. https://doi.org/10.1186/s13256-016-0851-5

Oyibo, S. O. (2019). Developing a beginner’s guide to writing a clinical case report: A pilot evaluation by junior doctors. Cureus. https://doi.org/10.7759/cureus.6370

Rison, R. A. (2013). A guide to writing case reports for the journal of medical case reports and biomed central research notes. Journal of Medical Case Reports, 7(1), 239, 1752-1947-7–239. https://doi.org/10.1186/1752-1947-7-239

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