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A case report is a description of important scientific observations that are missed or undetectable in clinical trials. This includes a rare or unusual clinical condition, a previously unreported or unrecognized disease, unusual side effects to therapy or response to treatment, and unique use of imaging modalities or diagnostic tests to assist diagnosis of a disease. Generally, a case report should be short and focussed, with its main components being the abstract, introduction, case description, and discussion.
Case reports should encompass the following five sections: an abstract, an introduction with a literature review, a description of the case report, a discussion that includes a detailed explanation of the literature review, and a brief summary of the case and a conclusion. Tables, figures, graphs, and illustrations comprise the supplementary parts and will enhance the case report’s flow and clarity.Unlike original articles, case reports do not follow the usual IMRAD (introduction, methods, results,and discussion) format of manuscript organization. As the format for case reports varies greatly among different journals, it is important for authors to read carefully and follow the target journal’s instructions to authors.
A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. It usually describes an unusual or novel occurrence and as such, remains one of the cornerstones of medical progress and provides many new ideas in medicine. It is a rapid short communication between busy clinicians who may not have time or resources to conduct large scale research. Some reports may contain an extensive review of the relevant literature on the topic.
Most journals publish case reports that deal with one or more of the following: 1) an unexpected association between diseases and symptoms; 2) an unexpected event in the course of observing or treating a patient; 3) findings that shed new light on the possible pathogenesis of a disease or an adverse effect; 4) unique or rare features of a disease; 5) unique therapeutic approaches; and 6) a positional or quantitative variation of anatomical structures from normal.
Different journals have slightly different formats for case reports. It is always a good idea to read some of the target journal’s case reports to get a general idea of the sequence and format. Here is a sample of case report.
Abstract
COVID-19 is a viral disease with a high infectivity rate. The full spectrum of the disease is not yet understood. This understanding may help in limiting potential exposure. We present a young man with diarrhoea, abdominal pain and hyponatraemia who turned out to be positive for COVID-19.
Background
COVID-19 is caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). Fever is a common presenting symptom, along with cough, dyspnoea, myalgia and fatigue. Severe cases may lead to organ dysfunction and death.
As with any infectious disease, one of the challenges with COVID-19 is to understand both the typical and atypical disease presentations. Atypical presentations carry the risk of going undetected for a longer duration, and in turn may lead to the spillover of the disease in a healthcare setting as well as the community.
Case presentation
A 27-year-old Indian man, with known type 2 diabetes, presented with a 5-day history of gradually progressive, moderate severity, generalised abdominal pain. The pain was accompanied by watery diarrhoea five to six times per day. He did not have any fever, sore throat, myalgias, influenza-like symptoms or shortness of breath. A review of systems was remarkable for dry cough of similar duration. There was no recent history of travel and no sick contacts or animal exposure.
On initial presentation, he was not febrile, tachypnoeic, tachycardiac or hypotensive. Physical examination revealed a patient in distress due to abdominal pain. There was mild generalised abdominal tenderness, but no guarding, rigidity or rebound. The chest examination showed coarse bibasal crackles. The rest of the physical examination was unremarkable.
Initial work-up revealed normocytic anaemia, thrombocytopaenia and non-elevated inflammatory markers. Two repeated samples confirmed asymptomatic hyponatraemia.Liver enzymes, renal function and the endocrine panel were unremarkable. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) was the probable cause of hyponatraemia.
On the first day of admission, the patient developed high-grade fever. He was placed under isolation and screened for viral respiratory infections. The patient turned out to be positive for COVID-19.
Differential diagnosis
Given the patient’s chief complaint of abdominal pain with diarrhoea, gastroenteritis was the initial working diagnosis. There was no food intake from outside and no sick contacts.Stool analysis for ova and parasites was negative. Also, ELISA immunoassay for Clostridium difficile toxin came out negative. Stool culture was unrevealing. Stool PCR for SARS-CoV-2 was unavailable in the local hospital lab.
Pancreatitis was another differential, but lipase was negative. Atypical pneumonia was another possibility considering the minimal respiratory symptoms and bilateral chest X-ray findings. The patient did not produce any sputum for culture, and two sets of blood cultures were negative. Due to hyponatraemia, Legionella pneumonia was considered; however, the urinary antigen was negative.
Viral pneumonia was another diagnostic possibility for which a viral panel was sent, which included SARS-CoV-2 PCR, which eventually came back positive and hence confirmed the diagnosis of the novel coronavirus pneumonia.
Treatment
The patient was initially started on ceftriaxone, azithromycin and oseltamivir as empirical therapy for community-acquired pneumonia. After the tests for COVID-19 PCR from nasal swab came positive, the patient received chloroquine phosphate 250 mg twice per day,darunavir/cobicistat 950mg daily and ribavirin 1200mg twice per day for 14 days, based on local guidelines. Ribavirin 1200mg twice per day was added to his antiviral regimen. The patient remained clinically stable throughout the hospital course until discharge.
Outcome and follow-up
The patient’s abdominal pain and diarrhoea resolved without any specific management. He did not require any ventilatory support during his stay. His SARS-CoV-2 PCR turned negative on repeat testing after2 weeks and he was discharged home.
Discussion
The novel coronavirus belongs to a group of severe acute respiratory syndrome-related coronaviruses. It outbroke in Wuhan, Hubei Province, China, in December 2019 and was declared a pandemic by WHO on 11 March 2020.
The most common clinical features are fever, dry cough, myalgia, anorexia and dyspnoea.Gastrointestinal symptoms such as diarrhoea, abdominal pain and vomiting have been previously seen with acute viral respiratory infections and reported recently as rare manifestations of COVID-19. The confirmation of a suspected case relies on SARS-CoV-2 RNA detection via PCR. Watery diarrhoea is present in SARS-CoV-1 infection secondary to virus replication within the intestinal cells. The presence of gastrointestinal symptoms in coronavirus infection (SARS-CoV-1 and SARS-CoV-2) can be linked to the distribution of ACE2 receptor, which is present in lung alveolar type 2 cells, as well as in enterocytes.Acute hyponatraemia is present in atypical pneumonia, especially Legionella. The underlying mechanism is the syndrome of inappropriate antidiuretic hormone (ADH) secretion.
There is a rapidly accumulating body of knowledge regarding the epidemiology,pathophysiology, clinical manifestations, infection control and management of COVID-19.Like any other RNA virus, SARS-CoV-2 attacks the host cell, and penetrates and enters the nucleus for replication. The virus has an affinity to ACE2 as binding receptors. This affinity is the probable reason that the lungs are the most commonly affected organs.
The response of the host organ can be from minimal symptoms to organ failure. T cell immune response to the coronaviruses has been studied in the past. Another common disease phenomenon observed and reported is a hypercoagulable state, which can be explained by the expression of ACE2 enzymes by the endothelium. Similarly, the gastrointestinal tract also expresses ACE2, leading to a viral attack of the system.
There is ongoing research to understand the pathophysiology of COVID-19 infection. An important aspect is to understand the atypical presentation of the disease. Timely detection of suspected cases with prompt isolation and screening is one of the factors that may help curb the spread in the community. Our patient had acute hyponatraemia, abdominal pain and diarrhoea with minimal respiratory symptoms, which he did not self-report. The cough history was elicited during a thorough review of the system. This atypical presentation led to inadvertent exposure to healthcare personnel. Therefore, during the pandemic, a similar presentation should be considered for COVID-19.
The Introduction gives a brief overview of the problem that the case addresses, citing relevant literature where necessary. The Introduction generally ends with a single sentence describing the patient and the basic condition that he or she is suffering from.
The Case Presentation provides the details of the case in the following order: patient description,case history, physical examination results, results of pathological tests and other investigations,treatment plan, expected outcome of the treatment plan and actual outcome. The author should ensure that all the relevant details are included and unnecessary ones excluded.
The Discussion is the most important part of the case report. It will convince the journal that the case is publication worthy. This section should start by expanding on what has been said in the Introduction, focusing on why the case is noteworthy and the problem that it addresses. This is followed by a summary of the existing literature on the topic. (If the journal specifies a separate section on literature review, it should be added before the Discussion.) This part describes the existing theories and research findings on the key issue in the patient’s condition. The review should narrow down to the source of confusion or the main challenge in the case. Finally, the case report should be connected to the existing literature, mentioning the message that the case conveys. The author should explain whether this corroborates with or detracts from current beliefs about the problem and how this evidence can add value to future clinical practice.
A case report ends with a Conclusion or with summary points, depending on the journal’s specified format. This section should briefly give readers the key points covered in the case report. Here,the author can give suggestions and recommendations to clinicians, teachers, or researchers. Some journals do not want a separate section for the conclusion: it can then be the concluding paragraph of the Discussion section.
Directions: Find more samples of case reports and identify their category .
Directions: Structure the case report according to the general journal format.
• Abstract/Summary
• Introduction
• Case Presentation
○ Patient’s description
○ Medical history
○ Physical examination
○ Analysis of test results
○ Differential diagnosis
○ Treatment plan and outcomes
• Discussion
○ Etiology/pathophysiology
○ Literature review
○ Ethical dilemmas (if any)
○ Conclusion
Directions: Use the patient’s notes to write a textbook style of case presentation without headings. (Remember to anonymize the data if necessary!)
(1)Laboratory testin g.Cholesterol levels high,300 mg/dL.Othertests negative.
__________
(2) Name John Smith Sex male
C/O nausea, recurrent vomiting, colicky abdominal pain, 5 days
PH hypertension
__________
(3) PE overweight, afebril, sweaty, distress
BP 140/90 HR 110 SaO2 97%
Nerological reflexic weakness both legs,symmetrically
__________
(4) Diagnosis gallstone ileus
Intervention enterotomy & cholelithotomy(5.2×3.6 cm)
Outcome good
__________
Directions: Complete an abstract for the case report below.
Bezoars are accumulation of foreign bodies formed of partially digested or non-digested foreign material in the gastrointestinal (GI) tract; most commonly found in the stomach but can be seen elsewhere in the digestive tube. Several types of bezoars are named according to the material from which they are composed. It could be food boluses composed of loose aggregate of food items, lactobezoar formed by inspissated milk usually seen in infants,pharmacobezoar formed by medical tablets and masses of drugs, phytobezoars composed of indigestible plant material, diospyrobezoar a type of phytobezoar formed by persimmons,trichobezoar formed by ingestion of hair and the least frequent being metal bezoar, usually seen in patients having psychiatric disorders. Few cases have been reported in the literature.
We present a case of a psychiatric man who was operated several times due to relapsing massive metal bezoars despite psychiatric treatment.
A 52-year-old male patient with chronic psychosis and under specific psychotic treatment,presented in May 2012 with signs and symptoms of gastric outlet obstruction due to the ingestion of metal bezoar, which was removed endoscopically. Eight months later, he was readmitted and operated because of failing endoscopic total removal of the different metals ingested. These bezoars were nails, knifes, screws, nuts, spoon handles, screwdriver head,washer, pebbles, coins and iron wire. Between 2013 and 2016, he was readmitted and operated two times in another institution for gastric metal bezoars after failed endoscopic removal in each intervention. The patient had laparotomy and metal bezoars were removed via gastrotomy.
Lately in December 2016, he was presented to the emergency department with fever and nausea; on physical examination, his vital signs were within normal limits except a moderate sinus tachycardia 110/min and 38°C. He was pale and dehydrated. Abdominal examination noted guarding throughout the abdomen, maximally in the epigastrium. A mobile mass was palpable in the left upper quadrant and epigastrium. He was admitted with provisional diagnosis of generalised peritonitis due to gastric perforation.
Blood tests revealed that the patient was septic with a haemoglobin level of 13 g/dL;peripheral white cell count was 20.1 109/L with neutrophils 85%. C-reactive protein was 200mg/L, urea 15mmol/L and normal creatinine. Abdominal CT scan showed a foreign body mass in the gastric region and small bowels associated with pneumoperitoneum and free intra abdominal fluid.
Differential diagnosis includes ulcer perforation, left transverse colon tumour. The patient ultimately underwent an open laparotomy, bezoars were removed via gastrotomy and many enterotomies since the radiologic perioperative findings help us to localise all the materials and to check for their total removal to prevent recurrence. The postoperative course was uneventful and the patient was discharged on postoperative day 15 with a referral to behavioural and mental health providers.
Bezoars are uncommon findings in the GI tract; they are composed of a wide variety of material depending on the type of the ingestion. Metal bezoar are the least common and very few cases are described in the literature. Bezoars are usually intentionally ingested, thus they occur in normal stomachs and are caused by foreign bodies that cannot bypass the pylorus.After reviewing the literature, metal bezoar was reported seven times. The first report was in 1956 by Salb and the second by Kaplan et al in 2005; later several cases were reported. None of the reported case was recurrent, complicated or massive.
However, other bezoars could occur in “abnormal” stomach, for instance, in cases of decreased gastric motility (eg, diabetes mellitus, previous vagotomy, drugs), previous gastrectomy (Billroth, gastric bypass), hypochlorydria, gastric stasis, loss of pyloric function and hypothyroidism. Clinical manifestations vary widely depending on the location of the bezoar that could be anywhere in, the digestive tract and can go from asymptomatic, non specific symptoms to more serious intestinal obstruction, GI bleeding, perforation and peritonitis. Metal bezoar can be seen on plain radiographs unless they are radiolucent but CT scan is usually necessary and help identifying localisation and possible complications due to these foreign bodies. Gastroscopy confirms the diagnosis, defines the type of the bezoar and could treat the bezoar by its removal if they were small and technically feasible. Although different treatments have been suggested to treat phyto-tricho-bezoars such as coca-cola,papaine saline and other chemical substances for dissolution, endoscopic extraction, surgical treatment is usually necessary for metal bezoars.
Metal bezoars could be a rare cause of abdominal concern. They are generally ingested accidentally in adults, usually in infants, elderly, psychotic patients and prisoners. The patient could be asymptomatic. Surgical exploration and extraction is the treatment of choice and thorough exploration of the whole digestive tract is necessary to avoid retained materials.Psychiatric follow-up is mandatory to prevent recurrence that has been reported to be 14% in the literature.
Abstract
A 52-year-old male patient with psychiatric medical history who presented to the emergency department five times during a period of5 years due to (1)______________________ manifested mainly by (2) ______________________ after intentionally ingesting metals and which necessitate several surgical interventions. Lately, he presented with (3) ______________________due to gastric perforation from metal bezoars. Chronic abdominal symptoms in patient having a psychiatric disorder can be due to (4) ______________________. Treatment is often surgical and the whole digestive tract should be explored to avoid (5) ____________________.