medical case study format pdf

Medical Case Study Template

Utilize our Medical Case Study Template for systematic documentation and analysis of patient cases, enhancing learning and clinical practice.

By Emma Hainsworth on Jul 15, 2024.

Fact Checked by Ericka Pingol.

What is a Medical Case Study Template?

A Medical Case Study Template is a systematic tool used primarily by healthcare professionals and students to document, analyze, and present individual patient cases. It serves as a structured guide, ensuring that all critical aspects of the case are captured and discussed in a standardized format. This includes patient information, clinical history, diagnostic assessments, treatments, and outcomes.

The template typically starts with a title and a brief abstract summarizing the case. It progresses through detailed sections covering patient demographics, symptoms, examination findings, and the results of any diagnostic tests. Treatment plans and their outcomes are also meticulously documented.

One of the key purposes of this template is educational. It facilitates learning by providing a comprehensive overview of real-life clinical scenarios, encouraging critical thinking and analysis. It's also used in medical research and literature to share clinical experiences and insights, contributing to the broader medical community's understanding of various conditions and treatments.

Using a Medical Case Study Template ensures a thorough and uniform approach to case documentation, which is essential for effective learning, discussion, and advancement in medical practice. It emphasizes the importance of detail and accuracy in clinical reporting, enhancing both educational value and patient care.

Medical Case Study Template Example

How does it work?

Here's a step-by-step guide to accessing and using our Medical case study template:

Step 1: Access and download the Medical Case Study Template

Click the link on this page to download and access the Medical Case Study Template. The template is available in a user-friendly PDF format, allowing for easy digital viewing and interaction.

You can print the template if a physical copy is preferred for note-taking or group discussions. This is especially useful in educational settings or during team meetings.

Step 2: Understand the structure of the template

Review the template to understand its various sections, which include patient information, clinical history, diagnosis, treatment, and outcome.

Note the specific details required in each section, such as demographic data, symptoms, test results, and follow-up care. Understanding these components is crucial for consistency and comprehensiveness in case documentation.

Step 3: Utilize the template for case documentation

Use the template to systematically record all relevant details of a patient case. This might be for educational purposes, research, or clinical documentation.

Regularly update the template with new information or follow-up details. This is important for tracking the case's progression and observing treatments' effectiveness.

Keep in mind that each patient case is unique. The template should be adaptable to accommodate the specificities of different medical scenarios.

Step 4: Review and share the documented case

Use the documented case for peer discussions, educational sessions, or team reviews. The structured format of the template facilitates easy sharing and collaborative analysis.

Encourage feedback on the documented case to enhance learning and improve clinical practices. The template can be a tool for reflective practice and continuous professional development.

By following these steps, healthcare professionals, educators, and students can effectively use the Medical Case Study Template for a range of purposes. This resource is invaluable for documenting individual cases and as a tool for education, research, and collaborative learning in the medical field.

When would you use this Template?

The Medical Case Study Template is an invaluable resource primarily used by healthcare professionals, medical students, and educators in various clinical and educational settings. Its application is particularly relevant and beneficial in several key scenarios.

Clinical education and training

Medical educators often use this template to teach students about real-life medical cases. It provides a structured approach to case analysis, encouraging students to examine all aspects of patient care, from diagnosis to treatment and follow-up. This methodical approach is crucial in developing critical thinking and diagnostic skills.

Peer learning and discussion

The template is used among healthcare professionals as a basis for case discussions, often in grand rounds or peer review meetings. It allows practitioners to present complex cases to colleagues, fostering collaborative analysis and discussion. This shared learning experience can lead to improved patient care strategies and a deeper understanding of rare or challenging cases.

Research and case reporting

When documenting unique or particularly instructive cases for medical research or publication, the Medical Case Study Template provides a comprehensive format. It ensures that all relevant details are systematically presented, making the case valuable for the wider medical community. This is especially important when contributing to medical journals or databases.

Quality improvement initiatives

In quality assurance and improvement activities within healthcare settings, this template can be used to analyze cases that highlight systemic issues or successes. It aids in identifying areas for improvement in patient care processes and protocols.

Personal professional development

For individual healthcare practitioners, the template serves as a tool for reflecting on challenging cases, allowing for self-assessment and continuous professional development.

Benefits of using this template ?

Using a Medical Case Study Template offers several significant benefits:

Standardized documentation: The template provides a uniform structure for documenting patient cases. This standardization is crucial for ensuring that all relevant details are consistently recorded and easy to find, which is particularly beneficial when multiple healthcare professionals review cases.
Enhanced educational value: For medical students and trainees, the template is an educational tool that promotes a thorough understanding of clinical cases. It encourages a holistic view of patient care, encompassing diagnosis, treatment, and follow-up, and helps in developing critical thinking and analytical skills.
Improved communication: When discussing patient cases with peers or in academic settings, the template aids in clear and concise communication. It ensures that all necessary information is presented in an organized manner, facilitating better understanding and discussion among medical professionals.
Quality of care and patient safety: By systematically documenting and reviewing patient cases, healthcare providers can identify trends, successes, and areas for improvement in treatment protocols. This can lead to enhanced patient safety and overall quality of care.
Facilitates research and publication: The template is invaluable for practitioners looking to publish case reports in medical journals. It ensures that the case is documented in a comprehensive and systematic manner, meeting the standards required for academic and research publications.
Professional development: Regular use of the template encourages practitioners to reflect on their clinical practice, helping them to identify areas for professional growth and development.
Consistency in case analysis: The template provides a consistent framework for analyzing and discussing patient cases. This consistency is essential for comparative analysis and for understanding the nuances of different cases.
Time efficiency: With a set structure in place, healthcare professionals can save time in documenting and reviewing cases, as they do not have to create a new format each time.

Commonly asked questions

A Medical Case Study Template is a structured document used to record and analyze patient cases in a systematic and detailed manner. It helps in documenting patient history, diagnosis, treatment, and follow-up, ensuring all crucial aspects of the case are covered.

Medical professionals, including doctors, nurses, and therapists, as well as medical students and educators, can benefit from using this template. It's also useful for researchers and clinicians involved in case studies for publication or presentation.

The template ensures comprehensive documentation of patient cases, which aids in better understanding and analyzing the patient's condition and treatment outcomes. This thorough approach can lead to more informed and effective patient care strategies.

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Writing a case report...

Writing a case report in 10 steps

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Peer review
Victoria Stokes , foundation year 2 doctor, trauma and orthopaedics, Basildon Hospital ,
Caroline Fertleman , paediatrics consultant, The Whittington Hospital NHS Trust
victoria.stokes1{at}nhs.net

Victoria Stokes and Caroline Fertleman explain how to turn an interesting case or unusual presentation into an educational report

It is common practice in medicine that when we come across an interesting case with an unusual presentation or a surprise twist, we must tell the rest of the medical world. This is how we continue our lifelong learning and aid faster diagnosis and treatment for patients.

It usually falls to the junior to write up the case, so here are a few simple tips to get you started.

First steps

Begin by sitting down with your medical team to discuss the interesting aspects of the case and the learning points to highlight. Ideally, a registrar or middle grade will mentor you and give you guidance. Another junior doctor or medical student may also be keen to be involved. Allocate jobs to split the workload, set a deadline and work timeframe, and discuss the order in which the authors will be listed. All listed authors should contribute substantially, with the person doing most of the work put first and the guarantor (usually the most senior team member) at the end.

Getting consent

Gain permission and written consent to write up the case from the patient or parents, if your patient is a child, and keep a copy because you will need it later for submission to journals.

Information gathering

Gather all the information from the medical notes and the hospital’s electronic systems, including copies of blood results and imaging, as medical notes often disappear when the patient is discharged and are notoriously difficult to find again. Remember to anonymise the data according to your local hospital policy.

Write up the case emphasising the interesting points of the presentation, investigations leading to diagnosis, and management of the disease/pathology. Get input on the case from all members of the team, highlighting their involvement. Also include the prognosis of the patient, if known, as the reader will want to know the outcome.

Coming up with a title

Discuss a title with your supervisor and other members of the team, as this provides the focus for your article. The title should be concise and interesting but should also enable people to find it in medical literature search engines. Also think about how you will present your case study—for example, a poster presentation or scientific paper—and consider potential journals or conferences, as you may need to write in a particular style or format.

Background research

Research the disease/pathology that is the focus of your article and write a background paragraph or two, highlighting the relevance of your case report in relation to this. If you are struggling, seek the opinion of a specialist who may know of relevant articles or texts. Another good resource is your hospital library, where staff are often more than happy to help with literature searches.

How your case is different

Move on to explore how the case presented differently to the admitting team. Alternatively, if your report is focused on management, explore the difficulties the team came across and alternative options for treatment.

Finish by explaining why your case report adds to the medical literature and highlight any learning points.

Writing an abstract

The abstract should be no longer than 100-200 words and should highlight all your key points concisely. This can be harder than writing the full article and needs special care as it will be used to judge whether your case is accepted for presentation or publication.

Discuss with your supervisor or team about options for presenting or publishing your case report. At the very least, you should present your article locally within a departmental or team meeting or at a hospital grand round. Well done!

Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare that we have no competing interests.

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J Med Case Rep

A guide to writing case reports for the Journal of Medical Case Reports and BioMed Central Research Notes

Richard a rison.

1 Presbyterian Intercommunity Hospital Health Stroke Program, Los Angeles County Medical Center, University of Southern California Keck School of Medicine, 12401 Washington Blvd, Whittier, CA 90602, USA

Case reports are a time-honored, important, integral, and accepted part of the medical literature. Both the Journal of Medical Case Reports and the Case Report section of BioMed Central Research Notes are committed to case report publication, and each have different criteria. Journal of Medical Case Reports was the world’s first international, PubMed-listed medical journal devoted to publishing case reports from all clinical disciplines and was launched in 2007. The Case Report section of BioMed Central Research Notes was created and began publishing case reports in 2012. Between the two of them, thousands of peer-reviewed case reports have now been published with a worldwide audience. Authors now also have Cases Database, a continually updated, freely accessible database of thousands of medical case reports from multiple publishers. This informal editorial outlines the process and mechanics of how and when to write a case report, and provides a brief look into the editorial process behind each of these complementary journals along with the author’s anecdotes in the hope of inspiring all authors (both novice and experienced) to write and continue writing case reports of all specialties. Useful hyperlinks are embedded throughout for easy and quick reference to style guidelines for both journals.

Introduction: the importance of case reports

Case reports are a time-honored tradition in the medical profession. From Hippocrates (460 B.C. to 370 B.C.), and even arguably further back since the papyrus records of ancient Egyptian medicine (c. 1600 B.C.) to modern day, physicians of all specialties have described interesting cases involving all specialties [ 1 , 2 ]. Published case reports provide essential information for optimal patient care because they can describe important scientific observations that are missed or undetected in clinical trials, and provide individual clinical insights thus expanding our knowledge base [ 3 ].

The publication of case reports has indeed become a standard lexicon of the medical literature. Examples abound. Few practicing physicians would not know for instance the significance and subsequent discovery of a disease whose first description in 1981 began with the title in the medical case report literature as: “A preliminary communication on extensively disseminated Kaposi’s sarcoma in a young homosexual man” [ 4 ]. There is no neurologist that I know who is unfamiliar with the disease whose description began in 1817 by James Parkinson (1755 to 1824) with the title “An essay on the shaking palsy.” [ 5 ].

Yes, both of the above-mentioned famous diseases (the acquired immunodeficiency syndrome and Parkinson’s disease) were first described in the case study format. The act of recording, discussion with colleagues, and publishing our clinical observations with patients remains essential to the art of medicine and patient care. As Osler once said “Always note and record the unusual…Publish it. Place it on permanent record as a short, concise note. Such communications are always of value.” [ 6 ].

But how and when should we do this? Early case reports were little more than personal communications between colleagues about unique and interesting patients seen in their respective medical practices. This anecdotal reporting has evolved into an accepted form of scholarly publication with the ability to rapidly disseminate knowledge to a broad medical audience [ 7 ] using the generally accepted format of a title, abstract, introduction (background), case presentation, discussion, conclusions, and references. Many biomedical journals publish case reports and provide authors with guidelines that provide instruction for acceptance criteria, content, and format and give advice on relevant patient case reports that merit publication [ 3 ].

There are already many well-written published articles on how and when to write a good case report (please see Recommended further reading section at the end). I will not re-invent the wheel, but within this editorial I hope to provide an informal guide on how and when to write a case report for BioMed Central (BMC), in particular the Journal of Medical Case Reports ( JMCR ) and BioMed Central Research Notes ( BMCRN ). The utility of the newly created Cases Database will also be discussed. Relevant and useful website links will be used throughout to allow the reader easy access to further information on BMC requirements. I also hope to impart to the reader a brief overview of case report editorial flow in both JMCR and BMCRN along with the complementary relationship between both journals. I will also give anecdotes of how I personally approach things.

Definitions

What exactly is a case report? From peer-reviewed journals to Wikipedia (and yes, I read Wikipedia like we all do) definitions are readily available and generally agreed upon. A simple online search shows the following definition from “thefreedictionary.com” [ 8 ]: “Case Report A report of a single case of a disease, usually with an unexpected presentation, which typically describes the findings, clinical course, and prognosis of the case, often accompanied by a review of other cases previously reported in the biomedical literature to put the reported case in context.” Wikipedia [ 9 ] has this to say: “In medicine, a case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence. Some case reports also contain a literature review of other reported cases.” Whether one uses the above definitional references or older more classic ones [ 10 ], all are in agreement.

How to start: the patient

Things start at the bedside or in the office with the most important person involved: the patient. Patients and their stories (including from their friends, coworkers, and family) are our portal to writing the case report. Patients (both in-patients and out-patients) are assessed, we confer with colleagues, appropriate investigations then follow, and treatment if possible begins. If I encounter an in-patient on call then I follow him or her throughout his or her hospitalization and, I hope, timely discharge. The patient is then followed and reexamined in the office over the course of time to see how the clinical course evolves. I usually wait 6 months over the course of multiple visits before I actually begin to write a case report so as to allow enough time for the clinical course to play out. Of course if the patient is hospitalized with an acute and rapid illness then this time may be much shorter, but I still follow him or her with daily neurologic examinations.

Collegial discussion and the Internet: our modern day water cooler

When an interesting condition is encountered in either the hospital or the office setting, I discuss the case in person with both my local neurology colleagues and colleagues of other specialties to see if they have encountered before the clinical scenario that I am dealing with at the time. This is usually a quick face-to-face nursing station conversation. If the case is particularly challenging then I will contact my local university colleagues for their opinion (especially if an urgent transfer needs to be arranged). I then “hit the books”, or at least I used to. Nowadays I usually “hit the keyboards” which are plentiful at every hospital nursing station and in my office. Indeed, the Internet seems to have become our modern day replacement for office water cooler conversations. Since it is readily available (and free to me because I am a member of the staff) in the hospital in which I see patients and in my office, I usually start with UpToDate® [ 11 ] and then click the links to individual references. Further reading is then supplemented by both PubMed [ 12 ] (free) and Cases Database (also free) [ 13 ] (see later). If I feel that a particular patient warrants a case report, then I continue to read more and more. There are also medical list servers and medical online communities to which one can post a case with de-identified images online and petition the advice of colleagues worldwide. I use both Neurolist [ 14 ] (a membership-only service, but membership is free) and The American Academy of Neurology (AAN) for my specialty and/or subspecialties [ 15 ] (also a membership-only service, the fee of which comes out of my yearly AAN dues). Another useful list server is sermo® [ 16 ], which has free membership. Teaching grand rounds at one’s local university or hospital, poster presentations, and simple discussion with professors giving lectures at local seminars are also good (and previously “traditional”) places to start. I have always preferred an in-person encounter to discuss a case with a colleague or professor, but given the current day and age (daily workload, travel costs, time away from the office and family, and so on), I have found Internet-based discussion (keeping all patient information anonymous of course) very helpful.

The BMC series, JMCR , and BMCRN : a brief history

The BMC series is a group of open access, peer-reviewed journals that spans most areas of biological and clinical research. There are currently 65 journals in the series, including (alphabetically) BMC Anesthesiology to BMC Women’s Health. Some of these publish case reports within their respective disciplines, and some do not [ 17 ].

JMCR is an online, open access journal under BMC auspices dedicated mainly to the publication of high quality case reports, and aims to contribute to the expansion of current medical knowledge (please see specific publication criteria below). It was created and founded by Michael Kidd and colleagues in 2007 and at the time was believed to be the world’s first international medical journal devoted to publishing case reports from all clinical disciplines. In the 5 years since its launch, JMCR has published over 2000 case reports. In 2011, case reports were downloaded from the journal’s website over 1,500,000 times [ 18 ].

BMCRN is also an online, open access journal under BMC auspices publishing scientifically sound research across all fields of biology and medicine. The journal provides a home for short publications, case series, and incremental updates to previous work with the intention of reducing the loss suffered by the research community when such results remain unpublished. BMCRN began publishing case reports in 2012 and now has a dedicated section for case reports [ 19 ].

Please read on to see the complementary relationship of case reporting between the two journals, how they relate to other journals in the BMC series, and further information on editorial work flow including specific publication criteria.

Cases Database: an invaluable resource

Since the launch of JMCR in 2007 and the more recent introduction of case reports to the BMCRN , which aims to have a broader scope, BMC has acknowledged and continues to acknowledge the value of case reports to the scientific literature. To further strengthen this commitment, BMC in conjunction with Michael Kidd have developed the invaluable new resource of Cases Database, a continually updated, freely accessible database of thousands of medical case reports from multiple other publishers, including Springer, British Medical Journal, and PubMed Central. By aggregating case reports and facilitating comparison, Cases Database provides a simple resource to clinicians, researchers, regulators and patients to explore content and identify emerging trends [ 20 ].

http://www.casesdatabase.com/

I find Cases Database indispensable when I research a particular patient’s condition. It is very helpful in seeing if a particular condition has been reported before and what treatment the authors have performed. It is an invaluable resource which can be used to check and see if previous cases have been reported before and how other authors have managed their patients with similar clinical conditions. When I last checked, Cases Database had in its repository 27,915 peer-reviewed medical case reports from 250 journals (!) [ 13 ]. Cases Database is quickly becoming my first go to when reading about a patient’s condition and symptoms.

When to write a case report

How does one determine when to write an actual case report? What constitutes and what are the criteria for publication? Different journals have different criteria, but here are the criteria for JMCR and BMCRN .

JMCR [ 21 ] publishes original and interesting case reports that contribute significantly to medical knowledge. Manuscripts must meet one of the following criteria: unreported or unusual side effects or adverse interactions involving medications; unexpected or unusual presentations of a disease; new associations or variations in disease processes; presentations, diagnoses and/or management of new and emerging diseases; an unexpected association between diseases or symptoms; an unexpected event in the course of observing or treating a patient; findings that shed new light on the possible pathogenesis of a disease or an adverse effect.

http://www.jmedicalcasereports.com/authors/instructions/casereport

BMCRN [ 22 ] has somewhat different publication criteria: BMCRN considers medical case reports that describe any clinical case. Case reports submitted to BMCRN do not need to be novel, but must be authentic cases and have some educational value along with representing at least an incremental advance in the field. BMCRN will not consider case reports describing preventive or therapeutic interventions because these generally require stronger evidence.

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport

Neither BMCRN nor JMCR will consider case reports where there are ethical concerns.

JMCR and BMCRN have the following definitions that authors should know: a single case report, two case reports, or a case series (greater than two reported cases). Both journals follow this format and accept submissions with these title structures.

I tend to classify case reports in my mind generally as follows: diagnosis-related, management-related, or both [ 10 ]. Either type should have clear and concise take-home messages and teaching points. I personally keep a stack of charts labeled “Curious Cases” on a bookshelf within my small office next to my desk which is always within my field of view at work, adhering to the “out of sight, out of mind” principle. Over the years that space has grown and, admittedly, I have cases dating back over the entire span of my years in practice (now over 13 years) which I simply have not gotten around to yet (!).

BMC editorial workflow for case reports: a brief glimpse

If a BMC Series journal editorial team considers a submitted case report unsuitable for their respective specialty journal (and now a growing list of Springer journals that BMC is now affiliated with), the authors are given the option to transfer their manuscript to BMCRN . If this option is exercised, then the BMC editorial team (usually the Case Report Section Editor for BMCRN in conjunction with the appropriate Associate Editor) determines if the manuscript is suitable for BMCRN or if it is more suitable for JMCR (based on the criteria listed above). The manuscripts will then be forwarded on to the respective Deputy and/or Associate Editors for peer review depending on which of the journals the author(s) agree(s) to. Peer reviewers are solicited (usually at least one at BMCRN and at least two at JMCR ). The peer review comments (which are open and identifiable at JMCR and blinded at BMCRN ) are then usually sent to the authors for appropriate revisions and rebuttals (unless it is felt that the manuscript should be rejected outright, at which time the editorial office sends the authors an explanatory letter). After these revisions and rebuttals have been performed, the revised manuscript and rebuttals are sent back to the respective editors for a final decision and recommendations. These decisions and recommendations are then forwarded on to the Editor-in-Chief for final approval for publication. At JMCR , manuscripts are professionally copyedited before being sent off to the production team for publication, whereas at BMCRN the authors are requested to obtain their own professional copyediting (if needed) before publication (the respective costs being reflected within the different article processing charges for both journals). When the manuscripts are published in both journals, they are in the preliminary form before being converted to the final form after production.

Author satisfaction consistently ranks high for the overall process in both journals.

The actual case report

Now let us discuss the brass tacks of writing the actual case report by going through the individual sections that will comprise the manuscript. I will present them in a sequence that matches the journals’ website requirements and provide easily accessible hyperlinks to both respective journals.

The first page of the manuscript should be a dedicated title page, including the title of the article. The title should be a clear and short description of the case with a list of the full names, institutional addresses and email addresses for all authors. There should always be at least one corresponding author who is clearly identified. Abbreviations within the title should always be avoided.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-title

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#title

I usually end the title with “…: a case report” or “…: two case reports” or “…: a case series”. I also try to avoid any puns or overly cute wording within the title and try to keep things strictly descriptive and clear. The title needs to accurately describe the case – after all, this may be all that someone reads. If a cute or clever title is used that obscures what the case is really about, then it may be even less likely that the manuscript is read.

The Abstract should be “short and sweet”. It should not exceed 350 words. Abbreviations or references within the Abstract should not be used. The Abstract should be structured into three sections: Background, an introduction about why this case is important and needs to be reported. Please include information on whether this is the first report of this kind in the literature; Case presentation, brief details of what the patient(s) presented with, including the patient’s age, sex and ethnic background; Conclusions, a brief conclusion of what the reader should learn from the case report and what the clinical impact will be. Is it an original case report of interest to a particular clinical specialty of medicine or will it have a broader clinical impact across medicine? Are any teaching points identified?

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-abstract

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#abstract

I find this is the most important part because this is often all that people will read and its availability will allow easy retrieval from electronic databases and help researchers decide their level of interest in the case report. The Abstract should be a concise and condensed version of the case report and should include the same main sections of the main text and be as succinct as possible [ 3 ]. This is the last thing that I usually write as it tends to flow easily after I have invested my time in thought and writing of the manuscript.

This section is comprised of three to ten keywords representing the main content of the article. It is important for indexing the manuscript and easy online retrieval.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-keywords

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-keywords

Introduction (Background)

The Introduction ( JMCR ) or Background ( BMCRN ) section should explain the background of the case, including the disorder, usual presentation and progression, and an explanation of the presentation if it is a new disease. If it is a case discussing an adverse drug interaction the Introduction should give details of the drug’s common use and any previously reported side effects. It should also include a brief literature review. This should give an introduction to the case report from the standpoint of those without specialist knowledge in the area, clearly explaining the background of the topic. It should end with a very brief statement of what is being reported in the article.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-intro

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#background

The Introduction or Background serves as the sales pitch for the rest of the manuscript. It should be concise and salient [ 3 ] and immediately attract the reader’s attention to entice him or her to read on.

Case presentation

This should present all relevant details concerning the case. The Case presentation section should contain a description of the patient’s relevant demographic information (without adding any details that could lead to the identification of the patient); any relevant medical history of the patient; the patient's symptoms and signs; any tests that were carried out and a description of any treatment or intervention. If it is a case series, then details must be included for all patients. This section may be broken into subsections with appropriate subheadings.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-case

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#presentation

This is one of the most integral sections. The case should be described in a concise and chronological order. One should usually begin with the primary complaint, salient history (including significant family, occupational, and other social history along with any significant medications taken or allergies), followed by the physical examination, starting with the vital signs presented at the examination, along with pertinent investigations and results. There should be enough detail (but not too much) for the reader to establish his or her own conclusions about the validity. It should contain only pertinent information and nothing superfluous or confusing [ 3 ].

This is an optional section in JMCR for additional comments that provide additional relevant information not included in the case presentation, and that put the case in context or that explain specific treatment decisions.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-discussion

This section should evaluate the patient case for accuracy, validity, and uniqueness and compare and contrast the case report with the published literature. The authors should briefly summarize the published literature with contemporary references [ 3 ].

Although this section is optional in JMCR (and not even listed separately on the BMCRN guidelines website), I find that most authors write this section, or an expanded conclusions section incorporating the elements listed above.

I personally write a separate discussion section and conclusions section for each case report that I author.

Conclusions

This should state clearly the main conclusions of the case report and give a clear explanation of their importance and relevance. Is it an original case report of interest to a particular clinical specialty of medicine or will it have a broader clinical impact across medicine? Information should be included on how it will significantly advance our knowledge of a particular disease etiology or drug mechanism (if appropriate).

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-conclusion

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#conclusions

This should be short and concise with clear take-home messages and teaching points [ 3 ].

Patient’s perspective

This section is an opportunity for patients to add a description of a case from their own perspective. The patients should be encouraged to state what originally made them seek medical advice, give a description of their symptoms, whether the symptoms were better or worse at different times, how tests and treatments affected them, and how the problem is now. This section can be written as deemed appropriate by the patients, but should not include identifying information that is irrelevant to the case reported. As medicine becomes more person-centered, the voice of the individual patient becomes even more important, both to assist in clinical decision making, and for medical education.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-patients

This optional section is unique to JMCR , and I believe adds an important new dimension to the traditional case report. Most authors still do not yet take advantage of this, but I hope as time goes on and more and more open access case report manuscripts are published that this section will be routinely used, not just in JMCR but also in BMCRN and all other BMC clinical journals. I recall one manuscript in particular where the patient himself was requesting publication as soon as possible because of his terminal disease. He wanted his message out there and be available to all to read before he died.

List of abbreviations

When abbreviations are used in the text they should be defined in the text at first use, and a list of abbreviations can be provided, which should precede the Competing interests and Authors’ contributions sections.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-abbreviations

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-abbreviations

Both JMCR and BMCRN publish case reports over a wide range of medical and surgical specialties, and it is important for the reader who may not be within that particular specialty to readily access a quick list of common technical abbreviations. Also, given the open access nature of both journals, please keep in mind that non-medical professionals may read the manuscript as well.

This section is compulsory for BMC. It should provide a statement to confirm that the patient has given their informed consent for the case report to be published. The written consent should not routinely be sent in along with the manuscript submission (because of patient privacy issues), but the BMC editorial office may request copies of the consent documentation at any time. The following wording is recommended: “Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.” If the individual described in the case report is a minor, or unable to provide consent, then consent must be sought from his or her parents or legal guardians. In these cases, the statement in the ‘Consent’ section of the manuscript should be amended accordingly. Please keep in mind that manuscripts will not be peer reviewed if a statement of patient consent is not present.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-consent

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#consent

In practice, I always start with written consent from the patient. If the patient is incapacitated or deceased, then I obtain consent from the patient’s next-of-kin. Once this is obtained then I place it in the patient’s chart for safe keeping. I find that most patients and family members are quite agreeable to publication as long as their details are anonymous. BMC has very clear and explicit consent criteria and consent forms in multiple languages. I always keep a consent form within my office (and carry a few in my doctor’s handbag for hospital consults) for ready access. After I have obtained consent, I place it in the patient’s chart and keep it my office.

If the patient has died, then I try to obtain consent from the patient’s next-of-kin. This is usually done via telephone or postal mail. If the deceased patient’s family is amenable (and usually they are), then I send them (I never use email when it comes to patient-identifying information) the pre-filled out consent form in their language with a return envelope and paid for postage via the postal service. If I am unable to obtain consent this way in a case involving a patient who has died, then I write in the Consent section the following: “Written informed consent could not be obtained from the deceased patient’s next-of-kin for publication of this case report and accompanying images despite all reasonable attempts. Every effort has been made to protect the patient’s identity and there is no reason to believe that our patient would have objected to publication.”

If the patient was last known to be living but untraceable (or mentally incapacitated without next-of-kin consent), then I just simply do not publish the case.

For further information, please see JMCR and BMCRN website consent section hyperlinks as listed above.

Competing interests

A competing interest exists when one’s interpretation of data or presentation of information may be influenced by a personal or financial relationship with other people or organizations. Authors must disclose any financial competing interests and should also reveal any non-financial competing interests that may cause embarrassment were they to become public after the publication of the manuscript. Authors are required to complete a declaration of competing interests. All competing interests that are declared will be listed at the end of published article. Where an author gives no competing interests, the listing should read “The author(s) declare that they have no competing interests”.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-competing

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-competing

I do not usually find any problems with competing interests in the case reports that I publish, but the section should always be completed in our era and in the spirit of complete disclosure.

Authors’ contributions

In order to give appropriate credit to each author of a paper, the individual contributions of authors to the manuscript should be specified in this section.

An ‘author’ is generally considered to be someone who has made substantive intellectual contributions to a published study. To qualify as an author one should: 1) have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) have been involved in drafting the manuscript or revising it critically for important intellectual content; and 3) have given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. Acquisition of funding, collection of data, or general supervision of the research group, alone, does not justify authorship. All contributors who do not meet the criteria for authorship should be listed in an Acknowledgements section. Examples of those who might be acknowledged include a person who provided purely technical help, writing assistance, or a department chair who provided only general support.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-contributions

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-contributions

I have found over the years a trend towards multi-authored case report manuscripts by many different individuals involved in the care of a patient(s). In my setting, it is usually me, a medical student or resident, a second-opinion tertiary colleague, and/or a pathologist or radiologist (if applicable). But I also recognize that there are situations that warrant more co-authors. The above criteria though for co-authorship should always be followed, and I have seen editorial situations where peer reviewers (including Associate Editors) have questioned what they felt was excessive authorship.

Authors’ information

This section includes any relevant information about the author(s) that may aid the reader’s interpretation of the article and understanding of the standpoint of the author(s). This may include details about the authors’ qualifications, current positions they hold at institutions or societies, or any other relevant background information. Please refer to authors using their initials. Note this section should not be used to describe any competing interests.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-information

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-information

In practice, I have frankly also personally used this section to advertise my services and “tout” my certifications and subspecialties (along with any co-authors and affiliated institutions) to my surrounding local community. This has in turn given me a modest increase in business (which has been completely non-monetary to date), usually in the form of email-based queries, many of which come from patients outside of my locality.

Acknowledgements

Authors should acknowledge anyone who contributed towards the article by making substantial contributions to conception, design, acquisition of data, or analysis and interpretation of data, or who was involved in drafting the manuscript or revising it critically for important intellectual content, but who does not meet the criteria for authorship. Also included should be the source(s) of funding for each author, and for the manuscript preparation. Authors must describe the role of the funding body, if any, in the: design, collection, analysis, and interpretation of data; writing of the manuscript; and decision to submit the manuscript for publication. Please also acknowledge anyone who contributed materials essential for the study. If a language editor has made significant revision of the manuscript, I recommend that you acknowledge the editor by name, where possible. Authors may also like to acknowledge (anonymously) the patient on whom the case report is based. If a scientific (medical) writer is used, this person should be included in the Acknowledgements section, including their source(s) of funding. Authors should obtain permission to acknowledge from all those mentioned in the Acknowledgements section.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-acknowledgements

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-acknowledgements

I have had colleagues who do not want to participate in the actual writing of the manuscript or do any actual “work” who have instead preferred to be mentioned in this section only.

Authors must search for and cite published case reports that are relevant to the case they are presenting. There should be no more than 15 references usually, although BMC does publish manuscripts with more references particularly if there is an extended literature review. Unless it is of historic interest, please keep the references as contemporary as feasible (for example, within the last 5 years or so). Please avoid excessive referencing.

http://www.jmedicalcasereports.com/authors/instructions/casereport#formatting-references

http://www.biomedcentral.com/bmcresnotes/authors/instructions/casereport#formatting-references

Cover letter

This is a separate document that should be written and uploaded with the main manuscript submission. I usually write this after I have written the Abstract. The cover letter should be addressed to the Editor-in-Chief in a formal manner and include all of the authors’ contact information. It should clearly and concisely state the title of the manuscript, and why the authors feel that their case report should be published based on any already available literature on the topic at hand. From an editor’s viewpoint, the cover letter is exceptionally important as that is the first thing that he or she reads and serves as the gateway to the Abstract and then the rest of the manuscript.

BMC author academy: help for all

Both JMCR and BMCRN have a large number of non-native English-speaking authors. Since JMCR and BMCRN are both BMC publications whose editorial offices are based in England, the language of publication is of course English. The BMC author academy is a joint program by BMC and Edanz [ 23 ] aimed at equipping writers for successful publication. Their materials have been developed from training workshops that Edanz gives to researchers worldwide and are not just limited to case reports. BMC recommends Edanz for authors who want to have their manuscript edited by a native speaker of English who is a scientific expert. Edanz provides scientific editing and related services that raise the quality of manuscripts to the standard needed to be understood at peer review.

http://www.biomedcentral.com/authors/authoracademy

I find that most non-native English-speaking authors have their manuscripts reviewed informally by a native English-speaking colleague and/or friend who is usually mentioned within the Acknowledgements section. This is understandable to keep costs down. However, please be aware that poor grammar and frequent spelling mistakes can be an impediment to editorial work flow and peer review. The editorial staff for both JMCR and BMCRN are acutely aware and sensitive to this given the large number of international submissions. At both JMCR and BMCRN , submitted manuscripts with questionable grammar and spelling are returned back to the authors by the editorial staff if it is felt that the grammar and spelling mistakes would impede peer review. If these issues are minor and it is felt that they would not impede peer review, then the manuscripts are sent off to peer reviewers (when appropriate).

Final checklist and the rule of C s

After I have completed a case report, I like to run through my long-winded (but useful) “rule of Cs” which is as follows.

Is it C lear, C oncise, and C oherent? Does it C onvey your message? Have you used C ases Database to look for any previously similar reported cases, and included them, if appropriate, in your references? Have you C onferred with your C olleagues on the C ontent? Will it C ause the reader to be C urious? Did you obtain C onsent? Does it C ontain all of the necessary information? Does it C omply with BM C guidelines? Do you think that it may need C opyediting? Do your C o-authors C oncur with the C ompleted paper? C an you C ut anything unnecessary out? Are your findings likely to be a C oincidence or by C hance alone? If so, then mention this in the Discussion section. Is the writing style C onsistent? Many times I find co-authored manuscripts have different writing styles within the same paper depending on who wrote what section. There should be a C entral, C orresponding author who is in C harge and oversees all of this. Is the C ase report written in a C hronological fashion with respect to the patient’s history and C hain of events? Is there anything that can be C ut out and have it still C ontain the C ompulsory information? Is it C oncise? Have you C onveyed C uriosity for your C ase report within your C over letter to the editorial team? Remember: your C over letter is the sales pitch to the editorial team! Make it C ount! Have you used within the manuscript C opyrighted information from another source? If so, do you need and/or have permission for use? After C ompletion, wait a C ouple of days before final submission to C lear your mind and read the manuscript again to C atch any mistakes that you may have made while you were C aught up in the C ompletion of it. Are the references C ontemporary? C an it be C omprehended by the average (“ C ”) reader? Remember, both JMCR and BMCRN are open access and freely available to anyone with an Internet C onnection and C omputer. C ast as wide a net as possible and C apture your C olleagues’ and other readers’ C uriosity. And first and foremost as a C linician: was the C are of your patient C ompetent and C ompassionate? (that is, are there any ethical concerns that may preclude peer review and publication?).

Summary and parting advice

Case reporting can be fun and a lifelong hobby, both for novice and experienced authors alike. It is now integral and widely accepted within published medical literature and today’s electronic information and data-sharing age. By following the above recommended steps and general overview, I hope to encourage BMC authors to continue to write and submit manuscripts to both JMCR and BMCRN . After your manuscript is complete, please follow the rule of “Cs”, especially “ C lear, C oncise, C oherent, C onsent, C ompassion, and C ompetence”, which will be appreciated by both reviewers and editors. Do not be afraid to obtain help from native English speakers for your manuscript. Also, please adhere to deadlines and follow instructions given by the editorial office, especially regarding any revisions. Editors read many different manuscripts and the longer it takes to get back a manuscript after revisions have been requested the less fresh that manuscript is in mind. Lastly, consider volunteering as an Associate Editor and/or reviewer within your specialty for both journals. I do for both, and the experience has improved both my writing and editing skills and daily interactions with patients.

Writing a Case Report

This page is intended for medical students, residents or others who do not have much experience with case reports, but are planning on writing one.

What is a case report? A medical case report, also known as a case study, is a detailed description of a clinical encounter with a patient. The most important aspect of a case report, i.e. the reason you would go to the trouble of writing one, is that the case is sufficiently unique, rare or interesting such that other medical professionals will learn something from it.

Case reports are commonly of the following categories :

- Rare diseases

- Unusual presentation of disease

- Unexpected events

- Unusual combination of diseases or conditions

- Difficult or inconclusive diagnosis

- Treatment or management challenges

- Personal impact

- Observations that shed new light on a disease or condition

- Anatomical variations

It is important that you recognize what is unique or interesting about your case, and this must be described clearly in the case report.

Case reports generally take the format of :

1. Background

2. Case presentation

3. Observations and investigation

4. Diagnosis

5. Treatment

7. Discussion

Does a case report require IRB approval?

Case reports typically discuss a single patient. If this is true for your case report, then it most likely does not require IRB approval because it not considered research. If you have more than one patient, your study could qualify as a Case Series, which would require IRB review. If you have questions, you chould check your local IRB's guidelines on reviewing case reports.

Are there other rules for writing a case report?

First, you will be collecting protected health information, thus HIPAA applies to case reports. Spectrum Health has created a very helpful guidance document for case reports, which you can see here: Case Report Guidance - Spectrum Health

While this guidance document was created by Spectrum Health, the rules and regulations outlined could apply to any case report. This includes answering questions like: Do I need written HIPAA authorization to publish a case report? When do I need IRB review of a case report? What qualifies as a patient identifier?

How do I get started?

1. We STRONGLY encourage you to consult the CARE Guidelines, which provide guidance on writing case reports - https://www.care-statement.org/

Specifically, the checklist - https://www.care-statement.org/checklist - which explains exactly the information you should collect and include in your case report.

2. Identify a case. If you are a medical student, you may not yet have the clinical expertise to determine if a specific case is worth writing up. If so, you must seek the help of a clinician. It is common for students to ask attendings or residents if they have any interesting cases that can be used for a case report.

3. Select a journal or two to which you think you will submit the case report. Journals often have specific requirements for publishing case reports, which could include a requirement for informed consent, a letter or statement from the IRB and other things. Journals may also charge publication fees (see Is it free to publish? below)

4. Obtain informed consent from the patient (see " Do I have to obtain informed consent from the patient? " below). Journals may have their own informed consent form that they would like you to use, so please look for this when selecting a journal.

Once you've identified the case, selected an appropriate journal(s), and considered informed consent, you can collect the required information to write the case report.

How do I write a case report?

Once you identify a case and have learned what information to include in the case report, try to find a previously published case report. Finding published case reports in a similar field will provide examples to guide you through the process of writing a case report.

One journal you can consult is BMJ Case Reports . MSU has a multi-year open access publishing agreement with the publisher BM J , and an institutional fellowship with BMJ Case Reports which allows MSU faculty, staff and students to publish in this journal for free. See this page for a link to the journal and more information on publishing- https://lib.msu.edu/collections/scholcomm/support

There are numerous other journals where you can find published case reports to help guide you in your writing.

Do I have to obtain informed consent from the patient?

The CARE guidelines recommend obtaining informed consent from patients for all case reports. Our recommendation is to obtain informed consent from the patient. Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports before publishing. The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible). Please consider this as well.

If required, it is recommended you obtain informed consent before the case report is written.

An example of a case report consent form can be found on the BMJ Case Reports website, which you can access via the MSU library page - https://casereports.bmj.com/ . Go to "Instructions for Authors" and then "Patient Consent" to find the consent form they use. You can create a similar form to obtain consent from your patient. If you have identified a journal already, please consult their requirements and determine if they have a specific consent form they would like you to use.

Seek feedback

Once you have written a draft of the case report, you should seek feedback on your writing, from experts in the field if possible, or from those who have written case reports before.

Selecting a journal

Aside from BMJ Case Reports mentioned above, there are many, many journals out there who publish medical case reports. Ask your mentor if they have a journal they would like to use. If you need to select on your own, here are some strategies:

1. Do a PubMed search. https://pubmed.ncbi.nlm.nih.gov/

a. Do a search for a topic, disease or other feature of your case report

b. When the results appear, on the left side of the page is a limiter for "article type". Case reports are an article type to which you can limit your search results. If you don't see that option on the left, click "additional filters".

c. Review the case reports that come up and see what journals they are published in.

2. Use JANE - https://jane.biosemantics.org/

3. Check with specialty societies. Many specialty societies are affiliated with one or more journal, which can be reviewed for ones that match your needs

4. Search through individual publisher journal lists. Elsevier publishes many different medical research journals, and they have a journal finder, much like JANE ( https://journalfinder.elsevier.com/ ). This is exclusive to Elsevier journals. There are many other publishers of medical journals for review, including Springer, Dove Press, BMJ, BMC, Wiley, Sage, Nature and many others.

Is it free to publish ?

Be aware that it may not be free to publish your case report. Many journals charge publication fees. Of note, many open access journals charge author fees of thousands of dollars. Other journals have smaller page charges (i.e. $60 per page), and still others will publish for free, with an "open access option". It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish. MSU-CHM does NOT have funds to support publication costs, so this is an important step if you do not want to pay out of pocket for publishing

*A more thorough discussion on finding a journal, publication costs, predatory journals and other publication-related issues can be found here: https://research.chm.msu.edu/students-residents/finding-a-journal

Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. 2013. The CARE guidelines: Consensus-based clinical case reporting guideline development. Glob Adv Health Med . 2:38-43. doi: 10.7453/gahmj.2013.008

Riley DS, Barber MS, Kienle GS, AronsonJK, von Schoen-Angerer T, Tugwell P, Kiene H, Helfand M, Altman DG, Sox H, Werthmann PG, Moher D, Rison RA, Shamseer L, Koch CA, Sun GH, Hanaway P, Sudak NL, Kaszkin-Bettag M, Carpenter JE, Gagnier JJ. 2017. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol . 89:218-234. doi: 10.1016/j.jclinepi.2017.04.026

Guidelines to writing a clinical case report. 2017. Heart Views . 18:104-105. doi: 10.4103/1995-705X.217857

Ortega-Loubon C, Culquichicon C, Correa R. The importance of writing and publishing case reports during medical education. 2017. Cureus. 9:e1964. doi: 10.7759/cureus.1964

Writing and publishing a useful and interesting case report. 2019. BMJ Case Reports. Link to document

Camm CF. Writing an excellent case report: EHJ Case Reports , Case of the Year 2019. 2020. European Heart Jounrnal. 41:1230-1231. https://doi.org/10.1093/eurheartj/ehaa176

*content developed by Mark Trottier, PhD

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A case study refers to a method or record of research on the creation over a period of time of a given person, community, or circumstance. In other words, it is a research method in the social and life sciences which involves an up-close, in-depth, and concise overview of a specific subject or topic. It is a research methodology and/or an empirical analysis that explores a topic in the context of its real life. A medical case study is the study of some specific operations in the medical field.

Step 1: Determine the Topic

Step 2: do your research, step 3: provide a good summary.

It must be informative.
It should summarize the narrative by presenting the client and their specific problems.
It should be able to illustrate what the main outcomes were.
It should illustrate primary outcomes like 1 or 2 statistics that bring the takeaway message home.

Step 5: Make a Rough Draft

Identify at least two to five key issues.
Determine the purpose of their existence.
Determine their impact on the organization.
Determine who is in charge of them.
Study the readings of the course, the interviews , the background beyond the case study.
Find compelling evidence that will support benefits and drawbacks. You need to ask yourself if the approach is realistic or not.

Step 6: Provide an Introduction

Step 7: insert the required elements, step 8: proofread, more in research templates.

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Article Information

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As Ozempic’s Popularity Soars, Here’s What to Know About Semaglutide and Weight Loss JAMA Medical News & Perspectives May 16, 2023 This Medical News article discusses chronic weight management with semaglutide, sold under the brand names Ozempic and Wegovy. Melissa Suran, PhD, MSJ
Patents and Regulatory Exclusivities on GLP-1 Receptor Agonists JAMA Special Communication August 15, 2023 This Special Communication used data from the US Food and Drug Administration to analyze how manufacturers of brand-name glucagon-like peptide 1 (GLP-1) receptor agonists have used patent and regulatory systems to extend periods of market exclusivity. Rasha Alhiary, PharmD; Aaron S. Kesselheim, MD, JD, MPH; Sarah Gabriele, LLM, MBE; Reed F. Beall, PhD; S. Sean Tu, JD, PhD; William B. Feldman, MD, DPhil, MPH
What to Know About Wegovy’s Rare but Serious Adverse Effects JAMA Medical News & Perspectives December 12, 2023 This Medical News article discusses Wegovy, Ozempic, and other GLP-1 receptor agonists used for weight management and type 2 diabetes. Kate Ruder, MSJ
GLP-1 Receptor Agonists and Gastrointestinal Adverse Events—Reply JAMA Comment & Response March 12, 2024 Ramin Rezaeianzadeh, BSc; Mohit Sodhi, MSc; Mahyar Etminan, PharmD, MSc
GLP-1 Receptor Agonists and Gastrointestinal Adverse Events JAMA Comment & Response March 12, 2024 Karine Suissa, PhD; Sara J. Cromer, MD; Elisabetta Patorno, MD, DrPH
GLP-1 Receptor Agonist Use and Risk of Postoperative Complications JAMA Research Letter May 21, 2024 This cohort study evaluates the risk of postoperative respiratory complications among patients with diabetes undergoing surgery who had vs those who had not a prescription fill for glucagon-like peptide 1 receptor agonists. Anjali A. Dixit, MD, MPH; Brian T. Bateman, MD, MS; Mary T. Hawn, MD, MPH; Michelle C. Odden, PhD; Eric C. Sun, MD, PhD
Glucagon-Like Peptide-1 Receptor Agonist Use and Risk of Gallbladder and Biliary Diseases JAMA Internal Medicine Original Investigation May 1, 2022 This systematic review and meta-analysis of 76 randomized clinical trials examines the effects of glucagon-like peptide-1 receptor agonist use on the risk of gallbladder and biliary diseases. Liyun He, MM; Jialu Wang, MM; Fan Ping, MD; Na Yang, MM; Jingyue Huang, MM; Yuxiu Li, MD; Lingling Xu, MD; Wei Li, MD; Huabing Zhang, MD
Cholecystitis Associated With the Use of Glucagon-Like Peptide-1 Receptor Agonists JAMA Internal Medicine Research Letter October 1, 2022 This case series identifies cases reported in the US Food and Drug Administration Adverse Event Reporting System of acute cholecystitis associated with use of glucagon-like peptide-1 receptor agonists that did not have gallbladder disease warnings in their labeling. Daniel Woronow, MD; Christine Chamberlain, PharmD; Ali Niak, MD; Mark Avigan, MDCM; Monika Houstoun, PharmD, MPH; Cindy Kortepeter, PharmD

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Sodhi M , Rezaeianzadeh R , Kezouh A , Etminan M. Risk of Gastrointestinal Adverse Events Associated With Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss. JAMA. 2023;330(18):1795–1797. doi:10.1001/jama.2023.19574

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Risk of Gastrointestinal Adverse Events Associated With Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss

1 Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
2 StatExpert Ltd, Laval, Quebec, Canada
3 Department of Ophthalmology and Visual Sciences and Medicine, University of British Columbia, Vancouver, Canada
Medical News & Perspectives As Ozempic’s Popularity Soars, Here’s What to Know About Semaglutide and Weight Loss Melissa Suran, PhD, MSJ JAMA
Special Communication Patents and Regulatory Exclusivities on GLP-1 Receptor Agonists Rasha Alhiary, PharmD; Aaron S. Kesselheim, MD, JD, MPH; Sarah Gabriele, LLM, MBE; Reed F. Beall, PhD; S. Sean Tu, JD, PhD; William B. Feldman, MD, DPhil, MPH JAMA
Medical News & Perspectives What to Know About Wegovy’s Rare but Serious Adverse Effects Kate Ruder, MSJ JAMA
Comment & Response GLP-1 Receptor Agonists and Gastrointestinal Adverse Events—Reply Ramin Rezaeianzadeh, BSc; Mohit Sodhi, MSc; Mahyar Etminan, PharmD, MSc JAMA
Comment & Response GLP-1 Receptor Agonists and Gastrointestinal Adverse Events Karine Suissa, PhD; Sara J. Cromer, MD; Elisabetta Patorno, MD, DrPH JAMA
Research Letter GLP-1 Receptor Agonist Use and Risk of Postoperative Complications Anjali A. Dixit, MD, MPH; Brian T. Bateman, MD, MS; Mary T. Hawn, MD, MPH; Michelle C. Odden, PhD; Eric C. Sun, MD, PhD JAMA
Original Investigation Glucagon-Like Peptide-1 Receptor Agonist Use and Risk of Gallbladder and Biliary Diseases Liyun He, MM; Jialu Wang, MM; Fan Ping, MD; Na Yang, MM; Jingyue Huang, MM; Yuxiu Li, MD; Lingling Xu, MD; Wei Li, MD; Huabing Zhang, MD JAMA Internal Medicine
Research Letter Cholecystitis Associated With the Use of Glucagon-Like Peptide-1 Receptor Agonists Daniel Woronow, MD; Christine Chamberlain, PharmD; Ali Niak, MD; Mark Avigan, MDCM; Monika Houstoun, PharmD, MPH; Cindy Kortepeter, PharmD JAMA Internal Medicine

Glucagon-like peptide 1 (GLP-1) agonists are medications approved for treatment of diabetes that recently have also been used off label for weight loss. 1 Studies have found increased risks of gastrointestinal adverse events (biliary disease, 2 pancreatitis, 3 bowel obstruction, 4 and gastroparesis 5 ) in patients with diabetes. 2 - 5 Because such patients have higher baseline risk for gastrointestinal adverse events, risk in patients taking these drugs for other indications may differ. Randomized trials examining efficacy of GLP-1 agonists for weight loss were not designed to capture these events 2 due to small sample sizes and short follow-up. We examined gastrointestinal adverse events associated with GLP-1 agonists used for weight loss in a clinical setting.

We used a random sample of 16 million patients (2006-2020) from the PharMetrics Plus for Academics database (IQVIA), a large health claims database that captures 93% of all outpatient prescriptions and physician diagnoses in the US through the International Classification of Diseases, Ninth Revision (ICD-9) or ICD-10. In our cohort study, we included new users of semaglutide or liraglutide, 2 main GLP-1 agonists, and the active comparator bupropion-naltrexone, a weight loss agent unrelated to GLP-1 agonists. Because semaglutide was marketed for weight loss after the study period (2021), we ensured all GLP-1 agonist and bupropion-naltrexone users had an obesity code in the 90 days prior or up to 30 days after cohort entry, excluding those with a diabetes or antidiabetic drug code.

Patients were observed from first prescription of a study drug to first mutually exclusive incidence (defined as first ICD-9 or ICD-10 code) of biliary disease (including cholecystitis, cholelithiasis, and choledocholithiasis), pancreatitis (including gallstone pancreatitis), bowel obstruction, or gastroparesis (defined as use of a code or a promotility agent). They were followed up to the end of the study period (June 2020) or censored during a switch. Hazard ratios (HRs) from a Cox model were adjusted for age, sex, alcohol use, smoking, hyperlipidemia, abdominal surgery in the previous 30 days, and geographic location, which were identified as common cause variables or risk factors. 6 Two sensitivity analyses were undertaken, one excluding hyperlipidemia (because more semaglutide users had hyperlipidemia) and another including patients without diabetes regardless of having an obesity code. Due to absence of data on body mass index (BMI), the E-value was used to examine how strong unmeasured confounding would need to be to negate observed results, with E-value HRs of at least 2 indicating BMI is unlikely to change study results. Statistical significance was defined as 2-sided 95% CI that did not cross 1. Analyses were performed using SAS version 9.4. Ethics approval was obtained by the University of British Columbia’s clinical research ethics board with a waiver of informed consent.

Our cohort included 4144 liraglutide, 613 semaglutide, and 654 bupropion-naltrexone users. Incidence rates for the 4 outcomes were elevated among GLP-1 agonists compared with bupropion-naltrexone users ( Table 1 ). For example, incidence of biliary disease (per 1000 person-years) was 11.7 for semaglutide, 18.6 for liraglutide, and 12.6 for bupropion-naltrexone and 4.6, 7.9, and 1.0, respectively, for pancreatitis.

Use of GLP-1 agonists compared with bupropion-naltrexone was associated with increased risk of pancreatitis (adjusted HR, 9.09 [95% CI, 1.25-66.00]), bowel obstruction (HR, 4.22 [95% CI, 1.02-17.40]), and gastroparesis (HR, 3.67 [95% CI, 1.15-11.90) but not biliary disease (HR, 1.50 [95% CI, 0.89-2.53]). Exclusion of hyperlipidemia from the analysis did not change the results ( Table 2 ). Inclusion of GLP-1 agonists regardless of history of obesity reduced HRs and narrowed CIs but did not change the significance of the results ( Table 2 ). E-value HRs did not suggest potential confounding by BMI.

This study found that use of GLP-1 agonists for weight loss compared with use of bupropion-naltrexone was associated with increased risk of pancreatitis, gastroparesis, and bowel obstruction but not biliary disease.

Given the wide use of these drugs, these adverse events, although rare, must be considered by patients who are contemplating using the drugs for weight loss because the risk-benefit calculus for this group might differ from that of those who use them for diabetes. Limitations include that although all GLP-1 agonist users had a record for obesity without diabetes, whether GLP-1 agonists were all used for weight loss is uncertain.

Accepted for Publication: September 11, 2023.

Published Online: October 5, 2023. doi:10.1001/jama.2023.19574

Correction: This article was corrected on December 21, 2023, to update the full name of the database used.

Corresponding Author: Mahyar Etminan, PharmD, MSc, Faculty of Medicine, Departments of Ophthalmology and Visual Sciences and Medicine, The Eye Care Center, University of British Columbia, 2550 Willow St, Room 323, Vancouver, BC V5Z 3N9, Canada ( [email protected] ).

Author Contributions: Dr Etminan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Sodhi, Rezaeianzadeh, Etminan.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Sodhi, Rezaeianzadeh, Etminan.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Kezouh.

Obtained funding: Etminan.

Administrative, technical, or material support: Sodhi.

Supervision: Etminan.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was funded by internal research funds from the Department of Ophthalmology and Visual Sciences, University of British Columbia.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement .

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Patient Case Study

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Case studies are a qualitative research method that offers a complete and in-depth look into some of the situations that baffled medical science. They document the cases that escape the ordinary in a hospital that has seen a manifold of plights. They serve as cautionary tales of the intricacy in dealing with human health.

It is a well-established empirical research approach that illuminates a stand-out case of a subject or a group of subjects. In the end, it seeks to introduce new information for the understanding of the nature of a disease or medical condition in the context of someone who has lived it. Patient case studies make a difference in the medical arena by reporting clinical interactions that can improve medical practices, suggest new health projects, as well as provide a new research direction. By looking at an event as it exists in the natural setting, case studies shed understanding on a complex medical phenomenon.

Case Study Pitfalls

Writing case studies can be no different than writing a research paper, with a few tweaks in the paper’s template and format. However, there are different blunders to avoid in preparing your report.

Since it documents stand-out clinical interactions where a single person or a few number of people are a party of, the findings may not be valid for generalization for a wider population. Therefore, you should avoid making motherhood statements and misleading conclusions just to make your study seem relevant where it isn’t. Your findings should stick to the evidence and data that you possess.

Because you are studying a case valid only for some people as of the moment, you should indicate the general scope and limitation of your work. The scenario might be different when placed in a different context. You should be honest in reporting the information about your study. Disclose the limits of your findings.

You are working on limited information. You should look into all of the possible explanations for the medical condition at hand. If a plight can be explained by more than one reason, then you have to look into the less obvious but similarly compelling explanations. Make your case study as informative as possible.

Case For Generalization

You cannot generalize a population using one case study. However, multiple case study contains two or more cases under the point of interest can give you a replicated result. When the findings remain true for several cases under this research method, your case study’s results become more reliable.

10+ Patient Case Study Examples

Medical practitioners use case studies to examine a medical condition in the context of a research question. They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. The following are case study samples and guides on case presentation.

1. Patient Information for Single Case Studies Example

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2. Sample Case Study Base on Acttual Patient Example

3. Ethical Legal Analysis of Patient Case Study Example

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4. Patient Audit Case Study Example

Patient Clinical Audit Case Study Example

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5. Brain Injury Patient Case Study Example

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6. Simple Patient Case Studies Example

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7. Cellulitis Patient Case Study Example

8. Not-for-Profit Hospital Patient Case Study Example

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9. Case Study of a Narcoleptic Patient Example

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10. Drugs Patient Case Study Example

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11. Patient Case Study in DOC

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Writing Your Patient Case Study

Since patient case studies are generally descriptive , they are under the a phenomenological principle. This means that subjectivity is entertained and allowed in research design. The medical scenarios are open to the researcher’s interpretation and input of insights. The following are reminders on how to prepare your case study analysis .

1. Work on Your Introduction

Select a case. You have to identify your focus and scope for the study. Like other research papers, you should prepare a research outline that guide you during the whole study duration. Another thing to produce is a related literature review. You should know about what you are going to study, and if any other investigation has been done on the material. When you have properly organized your information, you will have a smooth flow of ideas.

2. Get to Know the Participants

You can have one or multiple case participants. While other research methods boast of data credibility and generalizability, the small number of subjects in a case study is working for its advantage. The researcher is more attentive about his or her participants, and in-depth treatment of the study will not be very difficult. What case studies lack in generalized conclusions, they make up for thorough analysis of a subject matter.

3. Perform Data Analyses Method

Your results will depend on your interpretation of the raw data. Some researchers interpret their study data as the big picture while others dive into each pixel of the image. Be sure to extrapolate on all the possibilities that could help make sense of your case. You can compare your findings with present literature. Leave no stone unturned as you get down to the bottom of the investigation. Your data is only as good as your explanation.

4. Report the Case Study Results

Your patient case analysis is an investigation of a medical plight or case. When you present your findings, you have to balance the description of the situation and the detailing of the analyses. You have to illustrate how and why you came to a conclusion by providing the necessary background information. In the end, you can suggest future research or improvement built on what you have accomplished in this case study.

Against evidence-and-experiment-based research methods, case studies seem to have the lower end of the stick on the issue of reliability. However, case studies offer a comprehensive and exhaustive treatment on a complicated subject matter in a real-life setting. This research method lets you gain an appreciation for a concept beyond what cold, hard facts can provide. There is no single approach to science and knowledge.

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How to Write a Nursing Case Study + Examples, Format, & Tips
49 Free Case Study Templates ( + Case Study Format Examples + )
FREE 10+ Medical Case Study Samples & Templates in MS Word
Case Study Template
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FREE 10+ Nursing Case Study Templates in PDF

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PDF 10. Guideline and Template for Writing a Case Report/Case Series
retrospective study in Zambia, TB was more commonly diagnosed among children with Kwashiorkor (47%) compared to Marasmus-Kwashiorkor (24%) and marasmus (29%) [7]. The majority had pulmonary TB, while TB meningitis, lymphadenitis (as our case) and disseminated TB were the most common forms of extra-pulmonary TB.
Medical Case Study Template & Example
Step 1: Access and download the Medical Case Study Template. Click the link on this page to download and access the Medical Case Study Template. The template is available in a user-friendly PDF format, allowing for easy digital viewing and interaction. You can print the template if a physical copy is preferred for note-taking or group discussions.
PDF Writing and publishing a useful and interesting Case Report
Title of case. You do not need to include "a case report" in the title - you may be cryptic if you wish. Summary. This will be freely available online. Up to 150 words summarising the case presentation and outcome. We need a good flavour of the case - emphasise the learning points. Background.
Guidelines To Writing A Clinical Case Report
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 novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine. Some reports contain an extensive review of the relevant ...
PDF How to write a clinical case report
Below is the general format adopted for most case reports. Summarise your case report in a sentence. Mention how rare this condition is, and why your case report is important eg as a differential to consider in a patient presenting with X, Y and Z. Narrate your case in a way that is easy and enjoyable to follow.
How to write a medical case report
Writing a case report is an excellent way of documenting these findings for the wider medical community—sharing new knowledge that will lead to better and safer patient care. For many medical students and junior doctors, a case report may be their first attempt at medical writing. A published case report will look impressive on your ...
Writing a case report in 10 steps
Writing up. Write up the case emphasising the interesting points of the presentation, investigations leading to diagnosis, and management of the disease/pathology. Get input on the case from all members of the team, highlighting their involvement. Also include the prognosis of the patient, if known, as the reader will want to know the outcome.
Guidelines to the writing of case studies
It is best to simply tell the story and let the outcome speak for itself. With these points in mind, let's begin the process of writing the case study: Title page: Title: The title page will contain the full title of the article. Remember that many people may find our article by searching on the internet.
A guide to writing case reports for the Journal of Medical Case Reports
Case reports are a time-honored, important, integral, and accepted part of the medical literature. Both the Journal of Medical Case Reports and the Case Report section of BioMed Central Research Notes are committed to case report publication, and each have different criteria.Journal of Medical Case Reports was the world's first international, PubMed-listed medical journal devoted to ...
(PDF) Guideline on writing a case report
The. purpose of the case report is to expand our knowledge on. clinical manifestation, diagnostic approach, or therapeutic. alternative of a disease, ultimately, to improve the quality. of care ...
PDF Medical Case Study Format
Medical Case Study Format - Single and Multiple Authors. Title - The title is a summary of the abstract itself and should convince the reader that the topic is important, relevant, and innovative. Authors - Include name, degree and institutional affiliation. The authors included should be those who contribute significantly to the ...
Writing A Case Report
1. Do a PubMed search. https://pubmed.ncbi.nlm.nih.gov/. a. Do a search for a topic, disease or other feature of your case report. b. When the results appear, on the left side of the page is a limiter for "article type". Case reports are an article type to which you can limit your search results. If you don't see that option on the left, click ...
Medical Case Study
7+ Medical Case Study Templates and Examples. There is no manual for clinical operations that covers every possible medical case. Occasionally, health personnel would encounter a strange, undocumented condition of their patients. The life of a person is too delicate a constitution just to be handled carelessly.
PDF Composing a Case Study
Composing a Case Study A case study is a document used in many disciplines that examines unique or intriguing cases in order to gain some insight or understanding about the topic. Clinical case studies often look at individual cases or study different types of clinical practice. A case study may involve qualitative or quantitative research methods.
Health Case Studies
Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation.
PDF Case Study Template
Case Study Template CASE PRESENTATION Present the case, highlighting relevant details and findings. Please avoid identifying characteristics of the patients. HISTORY Share the history of the presenting condition, as well as pertinent medical and surgical history of the patient. Please include relevant family history, as indicated.
PDF CASE STUDY TEMPLATE
not be able to answer question (1-6) in this case, please proceed to question 7. 1. Symptoms, case history, the patient's and his/her family's medical history. In order to protect the patients' privacy please do not disclose the name of the patient on the case report form. 2. Physical examination, laboratory data, and diagnostic procedures.
PDF PRIMARY CARE CASE STUDIES 101 Sampath Wijesinghe 101
f Medicine, Elk Grove101 PRIMARY CARE CASE STUDIESSampath ("Sam") Wijesinghe, DHSc, PA-C, AAHIVS, is a principal faculty member and clinical site director for the Central Valley California region at Stanford University School of Medicine . s master's in science physician assistant program. He completed his PA education at Union College, where ...
FREE 11+ Medical Case Study Templates in PDF
A case study is referred to a process or record of research into the development of a particular person, group, or situation over a period of time. In other words, it is a research method in the social and life sciences which involves an up-close, in-depth, and concise overview of a specific subject or topic. It is a research methodology and/or an empirical analysis that explores a topic in ...
Clinical Case Study
The specialist can incorporate the medical history of the patient in his or her interpretation. This sample case study shows medicine and psychology can work together in the prevention of stress-induced asthma attacks. 6. Sample Clinical Case Study. citeseerx.ist.psu.edu. Details. File Format. PDF. Size: 85 KB.
PDF Clinical Case Studies for Students and Health Professionals
Clinical Case Studies 12/6/2018 2 . warnings can help to ease the toll of heat -related illness and prevention may ease the burden of such events on the health care system. Integrating weather modeling and public health intervention to address vulnerable populations may ease the burden of heat stress on individuals and the health care system.
Medical Case Summary
Disability Specific Summary - this consists of the information regarding the disability, cause of disability, diagnosis, treatment history and treatment plans. These are often used in claim management and other medical-related actions. Malpractice Incident Summary - this shows the cause of injury and its corresponding effect to the patient.
GLP-1 Agonists and Gastrointestinal Adverse Events
We used a random sample of 16 million patients (2006-2020) from the PharMetrics Plus for Academics database (IQVIA), a large health claims database that captures 93% of all outpatient prescriptions and physician diagnoses in the US through the International Classification of Diseases, Ninth Revision (ICD-9) or ICD-10. In our cohort study, we included new users of semaglutide or liraglutide, 2 ...
Patient Case Study
10+ Patient Case Study Examples. Medical practitioners use case studies to examine a medical condition in the context of a research question. They perform research and analyses that adhere to the scientific method of investigation and abide by ethical research protocols. The following are case study samples and guides on case presentation.
2024 R. G. Kar Medical College and Hospital rape and murder
On 9 August 2024, [12] a second-year postgraduate trainee (PGT) doctor [13] at R.G. Kar Medical College in Kolkata was reported missing by colleagues. At about 11:30 am, [14] the trainee doctor's body was discovered in one of college's seminar rooms in a semi-nude state with her eyes, mouth and genitals bleeding. She was later declared dead. An autopsy revealed that she had been raped and ...