Case Report Guide

Department of OBGYN Case Report Guidelines for Students

Scholarly activity and research in medical school comes in many forms. From “Bench” research, to clinical research involving randomized, double-blinded designs, to retrospective cohort studies the options for participation may seem overwhelming and you might just be asking yourself “How do I begin?”. One of the objectives of medical school is to gain an appreciation of how to interpret studies and data as well as gaining an appreciation for the challenges and benefits to society of conducting medical research. We believe that any student should be able to participate in research if they would like to. One way to participate is a Case Report. Case reports describe an unusual condition or therapy involving a patient that would be useful to other healthcare providers if faced with a similar patient or their condition. Despite not having as much rigor as other studies, they are often the most identifiable by practitioners and serve as a first line to the development of more rigorous study designs.

In order to help anyone participate in Case Reports, we have developed a checklist of things you will need to do when pursuing the development of a case report.

1) Find an interesting patient case. These usually will just happen to you but you may solicit cases from residents (they are working very hard and could use the assistance in their scholarly activities- that’s a place you can help!)

2) Let Leah know you are starting to develop a case report- have in mind which faculty and resident you plan to have participate

3) Perform a literature search on the subject. This can be done at the library of the school or at the hospital where you are. This first search does not need to be extremely exhaustive. You are looking for other case reports on the subject. If your “unusual case” has 50 reports, it may not be as unique or informative as you may hope it would be. Go back to the drawing board.

4) You must obtain consent from the patient to report their case. Despite de-identified information, unusual cases may have enough information to identify the patient. Especially if things like imaging studies are used

5) Once you have a case worth reporting- btw, it is ok to ask if you are not sure whether it is “Report Worthy”, you will need to find a faculty member (and maybe a resident- residents are usually hospital employees and the Case Report may be presentable at the research day at the individual hospital). The faculty involvement is required for IRB approval.

6) Do a more in depth literature search to see what questions have been answered and what may need to be elucidated more, and focus your discussion of the report on advancing knowledge in that realm, even if it just a miniscule bit.

7) Write up a draft of your proposal and contact Leah to schedule a group meeting with the faculty and residents involved with the case to review the draft.

8) Once the final abstract is completed and approved, Leah will take the lead in submitting the appropriate IRB forms for approval. IRB approvals are required from multiple institutions, such as John Peter Smith Hospital, UNTHSC and Harris Methodist Hospital, depending on the case.

9) You’re done. How Scholarly of you! Now we need to think about how to get the information about your interesting case to others. Some ideas:

a. UNT Research appreciation Day poster- Leah can help arrange

b. The research day at the hospital where the resident works- even if the resident presents the poster, you can list it as a presentation of the Case Report you were involved in on your CV.

c. Regional (TAOG and ACOG District 11, APGO, CREOG, SMFM, FIGO, etc. for OBGYN) or national meetings. Many will have different categories and some are exclusively for those in training.

d. Journal submission can help you get published. Make sure your case report complies with the journal’s requirements and don’t submit to more than one at a time. Leah can assist you with this process. If rejected by one journal, ask for feedback, modify and re-submit to the same or a different journal. There will be times that you will not be successful, use it as an opportunity to grow.

By following the above Case Report template, we hope it will be a very rewarding experience that is not too daunting as you try to assimilate all you are doing as you go through medical school. Consider it, we feel your education will be enhanced by participating. And finally, we are here to help!

Contact Information:

Hinkle, MD, FACOG
Associate Professor
Department of Obstetrics & Gynecology
Assistant to the Chair & Research Coordinator
Department of Obstetrics & Gynecology


Things to remember
when looking for “that” case:

1. Unreported or unusual side effects or adverse interactions involving medications

2. Unexpected or unusual presentations of a disease

3. New associations or variations in disease processes

4. Presentations, diagnoses and/or management of new and emerging diseases

5. An unexpected association between diseases or symptoms

6. An unexpected event in the course of observing or treating a patient

7. Findings that shed new light on the possible pathogenesis of a disease or an adverse effect

Guidelines for Writing an Abstracts for your Case Report


The abstract should be structured into three sections
and should make clear how the case report adds to the medical literature:

  • Introduction 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.
  • Conclusion 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? Please include information on how it will significantly advance our knowledge of a particular disease etiology or drug mechanism.


Three to ten keywords representing the main content of the article.


The Introduction 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.

Case presentation(s)

This should present all relevant details concerning the case. The case presentation 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 is for additional comments that provide any additional relevant information not included in the case presentation, and that put the case in context or that explain specific treatment decisions.


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 speciality of medicine or will it have a broader clinical impact across medicine? Please include information on how it will significantly advance our knowledge of a particular disease etiology or drug mechanism.


Include a list of your references. Search for and cite published case reports
that are relevant to the case being presenting.

This page was last modified on April 24, 2015