Dr Kgothatso Legong breaks down their tried-and-tested approach to writing good case reports.

My first case report was so splendidly done that I got called in to the clinical department and there I was interrogated as to who wrote it for me because I had to submit work done by myself. The interrogation soon turned out to be accolades masked as confirmation to the authenticity of my work. From then on, I went to write an even more charming case report which was appealing as it looked.

A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or new occurrence of a disease. For such reasons, it is vital to get yourself a patient with an interesting scenario which you could learn from.

This is how I approach case reports:

1. Stand out:

For your case report to be unique and interesting, you need to clerk as many patients as you possibly can. And from those patients, choose the one which interests you the most. For your case to stand out, you need a patient who also stands out.

2. Research:

The first patient I ever wrote a case report by had hyperthyroidism. At the time I was clerking her, I knew very little about what the diagnosis was. I had to do thorough research on her condition. This was helpful for me because I got to understand her presenting complaints which she had told me when I was clerking. Therefore, perform detailed research on the pathophysiology of your patient to consolidate clinical teaching with theoretical knowledge.

3. Consult your senior students and treating doctors:

Use what is disposable to you. Some of the medication prescribed to the patient confused me because that was my first time I have seen such. I found it helpful for me to consult senior students on what the medications actually were for. I further spoke with the treating registrar on her plan of management for the patient. The doctor went further to explain why they were keeping the patient and how the plan will change once the patient responds positively to the treatment.

4. Do not hold back:

Before submitting my final draft, I checked what other published case reports looked like. To my surprise my case report could not even hold a candle to what I discovered published in prestigious journals. Improvements had to be done. Formatted my case report to look professional by justifying the margins and putting the paragraphs in two columns. Then, put a fancy header and a footer, made sure page numbers existed then included my university’s emblem on the first page. The table were colourised, and pictures were captioned and numbered. I was all set.

5. Feedback:

It is good practice to submit a case report for review before submitting the final draft. I got feedback from the doctor in my unit on what I needed to improve and what I did well.  This was done five days before the final submission. You need to allow ample time for feedback to get back to you and make subsequent improvements.

I have since improved on my case report writing skills and hope to polish up this skill even more.