Introduction to Case Reports

If you've never experienced a case report in person this will give you an overview of how they work.

A case report is a meeting, usually with a small to medium sized group that discusses a particular patient.  These patient's are usually chosen because they either have an unusual disease, have an unusual presentation of a common disease, present a therapeutic challenge, or an ethical dilemma. The presentation is divided into several parts (based on how information about a patient is usually temporally collected and organized) to allow group discussion and further questioning.  The following describes my experience during my residency which is probably similar to other places.

To begin with, the presenter will give a brief one-three sentence introduction to the patient, something like "This is a 51 year old gentleman who is coming into the hospital with two days of abdominal pain" or "This is a 30 year old woman transferred to our hospital after seven days of worsening rash".  This will usually be followed by an overview of general questions you would ask every patient such as how long it has been going on for, where the symptom is located, etc...  Sometimes, in the interest of developing the participants' history taking skills, all of the history and review of systems (ROS) will need to be teased out through questioning.  For this to be particularly effective the presenter should also be asking the participants why they are asking certain questions, which will allow others to understand the reasoning behind certain lines of inquiry and how it can alter your differential diagnosis.

After the above back and forth to flesh out the HPI, the presenter will ask for initial differential diagnosis and why each one should be included.  So now we have an embryonic differential floating out there and the fun will be in seeing how more information will change/narrow our thoughts.

Next, the presenter will fill in all (unless there is some obvious juicy tidbit vital to the case) of the past medical history, meds, family history. The social history should be fleshed out by the participants, as it is often a very useful source of information in complicated patients. Sometimes there will be another pause to go back to the differential diagnosis or it will wait until after the next section.

After this will come the physical exam, and usually all the basic exam is given away.  If there are certain crucial exam findings that are beyond basic (basic usually defined as vital signs, general appearance, heart and lung sounds, abdomen, basic neuro exam, any obvious skin findings) these are withheld unless asked for by a participant.  Again, a jump back to the differential will occur at this point.

Finally, basic labwork will be given (CBC w diff, BMP, LFTs) and participants can ask for more labwork (if available) as well as the imaging studies, biopsy results, etc... that may or may not have been done (and of course the presenter should be asking "why" to every request so that others can understand why certain things are done).

It should be mentioned that at any point people can go back and ask a question pertaining to a previous part (for example, you might want to ask about travel history after seeing the eosinophils on the CBC).

Finally, we get together for one last discussion of the differential and the diagnosis is revealed.  There is usually some prepared learning from the presenter on the true diagnosis to cap it off (usually brief).  Sometimes, lingering questions that would best be served with a literature search are collected and an email is sent out with the results.

That is the basic overview.  The key to a good case presentation is participation and mutual respect.  Nobody should be felt like they are being pimped or ridiculed for asking a question since the point of this is to bring everybody up to a higher level. Case reports are great because they teach the method of diagnosing and deductive reasoning (something not easily conveyed in books) as well as information on particular disease. If nobody feels comfortable asking a question that might make them look ignorant than everybody suffers.

In Summary:
Brief Intro --> HPI/ROS (fleshed out by questions) --> Initial differential diagnosis --> Past medical history, family history, meds, etc... (Social Hx fleshed out) --> Differential revisited --> physical exam --> differential revisited--> labs/images/ecgs/pathology (fleshed out by questions) --> differential revisited --> Diagnosis revealed  --> Discussion