CHM Office of Reseach

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 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/medicalwriting_publishing/

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.  https://casereports.bmj.com/pages/wp-content/uploads/sites/69/2019/04/How-to-write-a-Case-Report-DIGITAL.pdf

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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How to Write a Medical Case Study Report

Last Updated: July 5, 2022 Fact Checked

This article was medically reviewed by Mark Ziats, MD, PhD and by wikiHow staff writer, Jennifer Mueller, JD . Dr. Mark Ziats is an Internal Medicine Physician, Scientist, Entrepreneur, and the Medical Director of xBiotech. With over five years of experience, he specializes in biotechnology, genomics, and medical devices. He earned a Doctor of Medicine degree from Baylor College of Medicine, a Ph.D. in Genetics from the University of Cambridge, and a BS in Biochemistry and Chemistry from Clemson University. He also completed the INNoVATE Program in Biotechnology Entrepreneurship at The Johns Hopkins University - Carey Business School. Dr. Ziats is board certified by the American Board of Internal Medicine. There are 16 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 183,864 times.

You've encountered an interesting and unusual case on your rounds, and a colleague or supervising physician says, "Why don't you write up a case study report?" If you've never written one before, that might sound intimidating, but it's a great way to get started in medical writing. Case studies always follow a standard structure and format, so the writing is very formulaic once you get the hang of it. Read on for a step-by-step guide to writing your first case study report.

What is a case study report?

Step 1 A case study report is an academic publication describing an unusual or unique case.

  • Medical students or residents typically do the bulk of the writing of the report. If you're just starting your medical career, a case study report is a great way to get a publication under your belt. [2] X Research source

Step 2 Your report discusses the case presented by one patient.

  • If the patient is a minor or is incapable of giving informed consent, get consent from their parents or closest relative. [4] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source
  • Your hospital likely has specific consent forms to use. Ask your supervising physician if you're not sure where to get one.
  • Some journals also have their own consent form. Check your target journal's author or submission information to make sure. [5] X Research source

How is a case study report structured?

Step 1 A typical report consists of an abstract, intro, case description, discussion, and conclusion.

  • Even though the introduction is the first part of a case study report, doctors typically write it last. You'll have a better idea of how to introduce your case study to readers after you've written it.
  • Your abstract comes at the top, before the introduction, and provides a brief summary of the entire report. Unless your case study is published in an open-access journal, the abstract is the only part of the article many readers will see.

Step 2 Check your target journal for possible variations.

  • Many journals offer templates and checklists you can use to make sure your case study includes everything necessary and is formatted properly—take advantage of these! Some journals, such as BMJ Case Reports , require all case studies submitted to use their templates.

Drafting Your Medical Case Study Report

Step 1 Pull all of the hospital records for the case.

  • Patient description
  • Chronological case history
  • Physical exam results
  • Results of any pathological tests, imaging, or other investigations
  • Treatment plan
  • Expected outcome of treatment
  • Actual outcome of treatment

Step 2 Write a draft of the case presentation.

  • Why the patient sought medical help (you can even use their own words)
  • Important information that helped you settle on your diagnosis
  • The results of your clinical examination, including diagnostic tests and their results, along with any helpful images
  • A description of the treatment plan
  • The outcome, including how and why treatment ended and how long the patient was under your care [11] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

Step 3 Research the existing literature on the patient's condition and treatment.

  • You will need references to back up symptoms of the condition, common treatment, and the expected outcome of that common treatment.
  • Use your research to paint a picture of the usual case of a patient with a similar condition—it'll help you show how unusual and different your patient's case is.
  • Generally, aim for around 20 references—no fewer than 15, but no more than 25. [13] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

Step 4 Write a section discussing the case in light of your research.

  • Close your discussion section with a summary of the lessons learned from the case and why it's significant to consider when treating similar cases in the future.
  • Outline any open questions that remain. You might also provide suggestions for future research.

Step 5 Complete your introduction and conclusion after you've written the body.

  • In your conclusion, you might also give suggestions or recommendations to readers based on what you learned as a result of the case.
  • Some journals don't want a separate conclusion section. If that's the case for one of your target journals, just move this paragraph to the end of your discussion section.

Polishing Your Report for Submission to Publishers

Step 1 Come up with a title for your case study.

  • Most titles are fewer than 10 words long and include the name of the disease or condition treated.
  • You might also include the treatment used and whether the outcome was successful. When deciding what to include, think about the reason you wrote the case study in the first place and why you think it's important for other clinicians to read.

Step 2 Identify the authors of the report on the title page.

  • Made a significant intellectual contribution to the case study report
  • Was involved in the medical care of the patient reported
  • Can explain and defend the data presented in the report
  • Has approved the final manuscript before submission for publication

Step 3 Write an abstract summarizing the entire article.

  • Keep in mind that the abstract is not just going to be the first thing people read—it will often be the only thing people read. Make sure that if someone is going to walk away having only read the abstract, they'll still get the same message they would have if they read the whole thing.
  • There are 2 basic types of abstract: narrative and structured. A narrative abstract is a single paragraph written in narrative prose. A structured abstract includes headings that correspond with the sections of the paper, then a brief summary of each section. Use the format preferred by your target journal.

Step 4 Choose keywords that will help readers find your case study.

  • Look for keywords that are relevant to your field or sub-field and directly related to the content of your article, such as the name of the condition or specific treatments you used.
  • Most journals allow 4-8 keywords but check the submission guidelines of your target journal to make sure.

Step 5 Obscure the patient's identity.

  • Blur out the patient's face as well as any tattoos, birthmarks, or unrelated scars that are visible in diagnostic images.

Step 6 Include your acknowledgments and conflict of interest statement.

  • It's common to thank the patient, but that's up to you. Even if you don't, include a statement indicating that you have the patient's written, informed consent to publish the information.
  • Read the journal's submission guidelines for a definition of what that journal considers a conflict of interest. They're generally the same, but some might be stricter than others. [22] X Research source

Step 7 Compile and format your reference section.

  • If you're not familiar with the citation style used by your target journal, check online for a guide. There might also be one available at your hospital or medical school library.
  • Medical librarians can also help with citation style and references if you run into something tricky—don't just wing it! Correct citation style insures that readers can access the materials you cite.

Step 8 Get feedback on your final draft.

  • It's also a good idea to get a beta reader who isn't a medical professional. Their comments can help you figure out where you need to clarify your points.
  • Read a lot of case studies published in your target journals—it will help you internalize the tone and style that journal is looking for.

Submitting Your Report to Publishers

Step 1 Choose target journals that publish similar content.

  • Look into the background and reputation of journals before you decide to submit to them. Only seek publication from reputable journals in which articles go through a peer-review process.
  • Find out what publishing fees the journals charge. Keep in mind that open-access journals tend to charge higher publishing fees. [26] X Research source
  • Read each journal's submission and editorial guidelines carefully. They'll tell you exactly how to format your case study, how long each section should be, and what citation style to use. [27] X Research source
  • For electronic journals that only publish case reports, try BMJ Case Reports , Journal of Medical Case Reports , or Radiology Case Reports .

Step 2 Submit your manuscript according to the journal's requirements.

  • If your manuscript isn't suitable for the journal you submitted to, the journal might offer to forward it to an associated journal where it would be a better fit.
  • When your manuscript is provisionally accepted, the journal will send it to other doctors for evaluation under the peer-review process.
  • Most medical journals don't accept simultaneous submissions, meaning you'll have to submit to your first choice, wait for their decision, then move to the next journal on the list if they don't bite.

Step 3 Revise your manuscript based on peer review comments.

  • Along with your revised manuscript, include a letter with your response to each of the reviewer's comments. Where you made revisions, add page numbers to indicate where the revisions are that address that reviewer's comments.
  • Sometimes, doctors involved in the peer review process will indicate that the journal should reject the manuscript. If that's the case, you'll get a letter explaining why your case study report won't be published and you're free to submit it elsewhere.

Step 4 Complete final copy-editing if the editors approve your article.

  • Some journals require you to have your article professionally copy-edited at your own cost while others do this in-house. The editors will let you know what you're responsible for.

Step 5 Pay the article processing charge if your article is accepted.

  • With your acceptance letter, you'll get instructions on how to make payment and how much you owe. Take note of the deadline and make sure you pay it as soon as possible to avoid publication delays.
  • Some journals will publish for free, with an "open-access option" that allows you to pay a fee only if you want open access to your article. [32] X Research source

Step 6 Sign your publishing agreement.

  • Through the publishing agreement, you assign your copyright in the article to the journal. This allows the journal to legally publish your work. That assignment can be exclusive or non-exclusive and may only last for a specific term. Read these details carefully!
  • If you published an open-access article, you don't assign the copyright to the publisher. The publishing agreement merely gives the journal the right to publish the "Version of Record." [34] X Research source

How do I find a suitable case for a report?

Step 1 Keep your eye out for unusual or interesting cases.

  • A rare disease, or unusual presentation of any disease
  • An unusual combination of diseases or conditions
  • A difficult or inconclusive diagnosis
  • Unexpected developments or responses to treatment
  • Personal impact
  • Observations that shed new light on the patient's disease or condition

Step 2 Discuss possible cases with your medical team.

  • There might be other members of your medical team that want to help with writing. If so, use one of these brainstorming sessions to divvy up writing responsibilities in a way that makes the most sense given your relative skills and experience.
  • Senior doctors might also be able to name some journals that would potentially publish your case study. [37] X Research source

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  • ↑ https://www.elsevier.com/connect/authors-update/the-dos-and-donts-of-writing-and-publishing-case-reports
  • ↑ https://www.bmj.com/content/350/bmj.h2693
  • ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686928/
  • ↑ https://health.usf.edu/medicine/internalmedicine/im-impact/~/media/B3A3421F4C144FA090AE965C21791A3C.ashx
  • ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
  • ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476221/
  • ↑ https://www.springer.com/gp/authors-editors/authorandreviewertutorials/writing-a-journal-manuscript/title-abstract-and-keywords/10285522
  • ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
  • ↑ https://thelancet.com/pb/assets/raw/Lancet/authors/tl-info-for-authors.pdf
  • ↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-017-1351-y
  • ↑ https://guides.himmelfarb.gwu.edu/casereports
  • ↑ https://casereports.bmj.com/pages/authors/
  • ↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-7-239
  • ↑ https://research.chm.msu.edu/students-residents/writing-a-case-report
  • ↑ https://www.elsevier.com/__data/assets/pdf_file/0006/98619/Sample-P-copyright-2.pdf
  • ↑ https://authorservices.taylorandfrancis.com/publishing-your-research/moving-through-production/copyright-for-journal-authors/#

About This Article

Mark Ziats, MD, PhD

Medical Disclaimer

The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment.

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To start a medical case study report, first choose a title that clearly reflects the contents of the report. You’ll also need to list any participating authors and develop a list of keywords, as well as an abstract summarizing the report. Your report will need to include an introduction summarizing the context of the report, as well as a detailed presentation of the case. Don’t forget to include a thorough citation list and acknowledgements of anyone else who participated in the study. For more tips from our Medical co-author, including how to get your case study report published, keep reading! Did this summary help you? Yes No

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How to write a medical case report

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  • Peer review
  • Seema Biswas , editor-in-chief, BMJ Case Reports, London, UK ,
  • Oliver Jones , student editor, BMJ Case Reports, London, UK

Two BMJ Case Reports journal editors take you through the process

This article contains...

- Choosing the right patient

- Choosing the right message

- Before you begin - patient consent

- How to write your case report

- How to get published

During medical school, students often come across patients with a unique presentation, an unfamiliar response to treatment, or even an obscure disease. 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 curriculum vitae, particularly if it is on a topic of your chosen specialty. Publication will be an advantage when applying for foundation year posts and specialty training, and many job applications have points allocated exclusively for publications in peer reviewed journals, including case reports.

The writing of a case report rests on skills that medical students acquire in their medical training, which they use throughout their postgraduate careers: these include history taking, interpretation of clinical signs and symptoms, interpretation of laboratory and imaging results, researching disease aetiology, reviewing medical evidence, and writing in a manner that clearly and effectively communicates with the reader.

If you are considering writing a case report, try to find a senior doctor who can be a supervising coauthor and help you decide whether you have a message worth writing about, that you have chosen the correct journal to submit to (considering the format that the journal requires), that the process is transparent and ethical at all times, and that your patient is not compromised in your writing. Indeed, try to include your patient in the process from the outset, and always gain consent.

A case report is the first line of medical evidence, and over time has become an important medium for sharing new findings (box 1). High quality case reports successfully bring together the various domains of medicine such as physiology, pathology, and anatomy. Using the patient as the focus, case reports provide a clinical “coat peg” on which to hang this knowledge.

Box 1: Notable case reports through the ages

Many case reports have changed the way clinicians view health and disease. For example, in 1861 the French surgeon Pierre Paul Broca reported the case of a dysphasic patient nicknamed “Tan”—owing to his inability to say any other words. After Tan’s death, Broca did an autopsy and discovered a syphilitic lesion in the frontal lobe of the brain, leading to the hypothesis of a speech centre in the brain—later known as Broca’s area. 1 Other notable case reports have documented the discovery of the Bence-Jones protein, 2 the first descriptions of Parkinson’s disease, 3 and AIDS. 4

Choosing the right patient

We can learn from all patients, but choose a patient from whom there is something new to learn. Search the literature and decide whether the topic you want to discuss, whether clinical or non-clinical (a radiological or microbiological finding, for example), has already been well discussed.

Your patient should ideally be someone who is not simply a willing participant in this process but someone who wants their story to be told to educate students, doctors, and other patients. Many journals have an option for patients to contribute to the manuscript.

Choosing the right message

Rare diseases are not in themselves a reason to write up a case, but unusual presentations of a common disease are important to communicate to the medical community. Early or subtle signs and symptoms that are easily missed are important for us to learn from. Indeed, the learning value of your case is the single most important factor in determining whether it is likely to be published.

Have in mind the journal that you want to submit your manuscript to before you begin to write. Your case and the message should fit with the style of the journal, whether a specialist journal, a case reports journal, or a journal that publishes case presentations in different formats. This may include question and answer formats, quizzes, or even interactive online educational formats useful for exam revision—for example, Endgames ( The BMJ ), Epilogue ( Archives of Disease in Childhood ), or Images ( New England Journal of Medicine ). These adapted formats are important, as most of these journals no longer accept case reports written in their traditional format.

Also, be careful in your claims about new diseases and new treatments. Case reports cannot make claims about the efficacy of novel treatments on the basis of individual cases and limited follow-up time. The most important message is a new or novel learning point—that is, the educational message.

Before you begin

Once you have chosen your patient and discussed with them what you would like to write, show them the case report so that they may give informed consent to your manuscript submission and familiarise themselves with the website.

It is important that a patient understands how their case will appear online or in print and that they truly give informed consent. You should do this under the supervision of the senior doctor who is the supervising coauthor of your manuscript; ideally, the senior doctor would obtain consent.

Writing the case report

Case presentation.

Begin with the case presentation (box 2): describe your encounter with the patient, their symptoms, and their signs. You should already have an idea what your take home messages will be. If the journal presentation of the case report allows, you can write these take home messages as bullet points (box 3).

Box 2: Case presentation

Acute pancreatitis and severe hypertriglyceridaemia masking unsuspected underlying diabetic ketoacidosis.

After 48 hours of anorexia, nausea, and non-bloody vomiting at home, the patient presented to her local hospital, where the diagnosis of moderate acute pancreatitis was made, based on an abdominal computed tomogram and ultrasound and serum chemistry. Ongoing symptoms, including left upper quadrant, 7/10 stabbing pain with generalised abdominal cramps, led to her transfer to the closest tertiary hospital for further management.

On admission to the tertiary hospital, the patient was treated as having uncomplicated pancreatitis. Immediate management included intravenous rehydration therapy, antiemetics, and narcotics for pain control with further orders for nothing to be ingested until the patient was re-evaluated. Initial assessment of the patient showed a temperature of 37.3ºC, heart rate 110 beats/min, blood pressure 126/68 mm Hg, respiratory rate 14 breaths/min, and oxygen saturation 98% on room air. She had a normal body habitus and was not in distress; however, she had a moderate amount of abdominal discomfort. Her physical examination showed no xanthalasmas or skin eruptions, nor was a fruity odour detected. Her gastrointestinal examination showed diffuse tenderness, with a soft, non-distended abdomen. Also, no organomegally was noted. Other than tachycardia, her cardiorespiratory examination was unremarkable with the notable absence of tachypnoea.

The patient was previously healthy without any medical history or surgical history. Her medication list was limited to the oral contraceptive pill (ethinyl oestradiol, norgestimate). The patient described only occasional social alcohol consumption (none within the last week) and no binge drinking or recreational drug use in the past. There were no recent surgeries, gastrointestinal endoscopic procedures, or abdominal trauma. She denied fever, chills, rigors, or recent unintended weight loss. There was no history of polyuria or polydipsia.

She did not have any prodromal abdominal symptoms There had been no similar episodes previously. There was no family history of dyslipidaemias, pancreatitis, or gallstones. Her family history was relevant for rectal carcinoma in her paternal grandfather and type 2 diabetes in her maternal grandmother. Six hours after her arrival at the tertiary hospital, and 12 hours from her first presentation and assessment at the local rural hospital, the patient began to decompensate with rapid progression of hypotension, tachycardia, and tachypnoea. The acute decompensation to hypotension and shock was assumed to be due to progression of the pancreatitis with potential infection complicating the pancreatitis. The patient was aggressively rehydrated and started on broad spectrum antibiotics. However, the hypotension failed to respond to fluid resuscitation and there was increased patient distress. She was urgently referred to the intensive care unit for supportive measures and management.

Aboulhosn K, Arnason T. Acute pancreatitis and severe hypertriglyceridaemia masking unsuspected underlying diabetic ketoacidosis. BMJ Case Rep 2013;2013, doi: 10.1136/bcr-2013-200431 .

Box 3: Learning points

Postpartum hellp syndrome and subcapsular liver haematoma.

Subcapsular liver haematoma is a potentially life threatening complication of severe pre-eclampsia and haemolysis, the breakdown of red blood cells; elevated liver enzymes; low platelet count syndrome.

The complication is rare but should be considered with severe upper abdominal pain in obstetric patients, especially in the presence of pre-eclampsia.

Real time ultrasound imaging of the liver is often diagnostic.

Messerschmidt L, Andersen LL, Sorensen MB. Postpartum HELLP syndrome and subcapsular liver haematoma. BMJ Case Rep 2014, doi: 10.1136/bcr-2013-202503 .

You should separate your case presentation section from the investigations and differential diagnoses. The key points to remember to include are your choice of investigations and how they helped you establish a working diagnosis (box 4).

Box 4: Investigations

Unilateral presentation of postpartum cardiomyopathy misdiagnosed as pneumonia.

On arriving at the emergency department, the patient had severe shortness of breath at rest 10 days after delivery. Her vital signs included an oral temperature of 36.7ºC, blood pressure 163/102 mmHg, pulse rate 146 beats/min, and oxygen saturation 88% in room air. Treatment with supplemental oxygen by mask yielded an increase in oxygen saturation to 95%. Her physical examination revealed no jugular venous distension, hepatic enlargement, or pedal oedema; heart sounds were fast and regular, with no evidence of murmurs or additional sounds. On lung auscultation bilateral crackles were present. Her laboratory analysis showed mild non-specific indicators of stress with a leucocyte count of 9.3×10 3 cells/mm 3 , haemoglobin value of 10.6 g/dL, and a platelet count of 791×10 3 cells/mm 3 . Her electrocardiogram was similar to the one obtained a day earlier showing T wave inversion in leads V4–V6; however, chest radiography showed a more bilateral presentation compared with the previous one showing both heart enlargement and pulmonary oedema. A chest computed tomography angiography performed to exclude pulmonary artery embolisation confirmed the presence of cardiomegaly and pulmonary oedema with bilateral effusions (fig 1). ⇓ An echocardiogram showed a diminished ejection fraction of 15-20% confirming the diagnosis of postpartum cardiomyopathy.

Amit BH, Marmor A, Hussein A. Unilateral presentation of postpartum cardiomyopathy misdiagnosed as pneumonia. BMJ Case Rep 2010, doi: 10.1136/bcr.05.2010.3039 .

Figure1

Fig 1 Chest computed tomogram performed after deterioration showing heart enlargement, pulmonary oedema, and bilateral pleural effusions mainly on the right. From Amit BH et al. BMJ Case Rep 2010, doi: 10.1136/bcr.05.2010.3039 .

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Imagine that you are presenting at a grand round and have to explain your choices to your colleagues—this is essentially what you are doing as you write your case report. Do not simply list your differential diagnoses; describe how you worked through your list of differentials and how you established a final diagnosis.

Also, make sure you collect and include high quality and well annotated images that not only explain radiological findings but also show their importance in establishing your diagnosis.

Good quality annotated images

Figure2

Fig 2 Craniocervical x ray film showing fusion of the posterior arch of C1 to the occiput. A fracture was not evident, but clinical suspicion prompted a computed tomography scan

Figure3

Fig 3 Axial, left, and sagittal, right, computed tomography scans of the craniocervical junction at presentation showing fusion of the left occipital condyle with the lateral mass of C1 and a fracture involving both elements. The fracture is indicated by the arrowheads

Outcome and follow-up

The outcome and your follow-up of the patient are important. In both your case presentation and the section on patient outcome, you should describe what happened to your patient in terms of their specific symptoms, their general wellbeing, and their lifestyle and activity.

Some journals require you to write a summary of your case report. This usually has a word limit and appears in medical search engines, such as Pubmed/MEDLINE. It is the equivalent of the abstract of a research paper.

Ensure that your title is scientific and clinical. Cryptic and humorous titles translate poorly across a global audience and do not always accurately reflect the content of your case report. You may find that the word limit does not permit you to write all the detail you would want to include in the summary, but the background section allows you to do this. Try to make sure that the background section does not repeat the summary.

Publication process

Clinical videos and images are important alternatives or potential additions to clinical case reports which many journals encourage authors to submit. Again, prepare these in collaboration with clinical teachers or coauthors, who will help you annotate these images and point out important learning messages, and do this from the outset in the format of the journal that you have researched well and decided to submit your manuscript to.

All submitted case reports are usually sent for peer review. Reviewers are chosen according to their specialty and clinical or academic interests. Your choice of key words is therefore important as these are the basis for the assignment of reviewers. Keywords are also important for other authors doing literature searches who discover your case report and cite this in their own writing.

Decisions to accept, revise, or reject are based on editors’ and reviewers’ opinions together, and every attempt is made to ensure that criticism is constructive and useful.

Dependent on how quickly your manuscript is reviewed, you should receive a decision on your manuscript within three to six weeks of submission. Outright rejections for reasons such as the unsuitability of your manuscript for the particular journal and its audience, manuscripts in the wrong format, incomplete sections (especially the case presentation and differential diagnosis sections), and plagiarism tend to be prompt, and they would be easily avoided by following the steps above and choosing your patient, your topic, your journal, and your particular manuscript format well.

Rejections on the basis of the content of the case report tend to be at the peer review stage and may be a few weeks after submission. They could include reasons such as the lack of novelty or educational message, a poor literature search, or inconsistent clinical management. Again, this is avoidable by preparing well. It is unusual for a well thought out and well prepared manuscript to be rejected.

Autoformatting software, especially with references, may produce errors, so do double check these. Syntax errors, spelling mistakes, and poor grammar create a poor impression of an otherwise good case report. As always, first impressions matter, so be meticulous as you proofread your manuscript before you submit.

The entire process of publication depends on the number of revisions necessary and how quickly you submit a revised manuscript. For those of you aiming to submit in time to prepare for job applications, do take into account the time taken in the process of publication.

Further reading

1. BMJ Case Reports has produced a ‘‘How to’’ guide for completing case report submission: http://casereports.bmj.com/site/about/How_to_complete_full_cases_template.pdf .

2. BMJ Case Reports has produced a clinical case reports template which illustrates the important points in a manuscript and should help you in your writing: http://casereports.bmj.com/site/about/guidelines.xhtml .

3. Some journals recommend patient perspectives in the write up of a case report. An example is at http://casereports.bmj.com/content/2015/bcr-2014-208529.full?sid=bb53a333-2c59-453a-a9bf-5775edc0e5d7 .

Originally published as: Student BMJ 2016;24:h3731

Competing interests: SB and OJ are editors of BMJ Case Reports.

Provenance and peer review: Commissioned; not externally peer reviewed.

  • ↵ Broca P. Remarks on the seat of the faculty of articulated language, following an observation of aphemia (loss of speech). Bulletin de la Société Anatomique . 1861 ; 6 : 330 -57. OpenUrl
  • ↵ Jones HB. On a new substance occurring in the urine of a patient with mollities ossium. Philosophical Transactions of the Royal Society of London . 1848 ; 138 : 55 -62. OpenUrl CrossRef
  • ↵ Parkinson J. An essay on the shaking palsy, 1817. J Neuropsych Clin Neurosci 2002 ; 14 : 223 -6. OpenUrl CrossRef PubMed Web of Science
  • ↵ Gottlieb GJ, Ragaz A, Vogel JV, et al. A preliminary communication on extensively disseminated kaposige sarcoma in a young homosexual man. Am J Dermatopath 1981 ; 3 : 111 . OpenUrl CrossRef PubMed Web of Science

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FREE 10+ Medical Case Study Samples & Templates in MS Word | PDF

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How is a medical case study done? In the American medical drama series titled House, you can see Dr. House and his team of doctors do a little huddle and a lot of whiteboard scribbling. Now, they’re actually not having a meeting, but they’re conducting a medical case study of their patient. Medical case studies are commonplace for doctors, especially those who are working in the hospital. Studying the case of each patient allows doctors to find the best treatment plan  based on the patient’s condition. So, how does this medical case study work? Let’s find out.

Medical Case Study

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Once complete, medical case studies are reported to hospital heads for further research. Here, we have medical case study samples and templates to help you with making a presentable  case report output.

medical center case study template

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sample control study for prospective case

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medical treatment case study template

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sample medical education case study

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school hospital case study template

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medical nutrition case study template

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hospital case study sample

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children hospital case study template

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medical database case study

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medical governance case study

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A medical case study is an in-depth or thorough investigation of a health condition, particularly those that are rare or illnesses that are elicited differently from the usual. Data gathering and analysis of data play an important role in this study because it is the means by which doctors and other medical practitioners can correctly diagnose the patient’s condition. Doctors go through trial and error before an actual diagnosis is decided. There are risks in a trial and error process; that is why the benefits should always outweigh the risks when it is done. The focus of a medical case study is on the identification and treatment of a known or unknown disease. Before the case is put into writing, a brainstorming session between the members of the medical team takes place. This is where the exchange of information and the realization of the data gathered is used.

The information gathered for a medical case study is biological. They are information about the patient’s past and present day-to-day activities. The methods used in a case study are determined through research. Different methods are essential in the study because it helps in making suitable materials for the case. Medical case studies greatly help in furthering the knowledge of doctors and other medical professionals in their field of expertise. It is a study material that applies both medical theory and actual practice. Similar case studies include a  nursing case study and a patient case study .

A medical case study requires time, patience, and a lot of knowledge on the case at hand. Formatting the study is simple. The difficult part is putting together all of the information gathered and make some sense out of it that will help find a treatment for a patient’s illness. To help you prepare your medical case study, here are a few steps that will help you get started.

Base the design, style, and format of your case study according to your audience or readers. Using the audience’s references over your style will help them effectively understand your medical presentation, especially if it is about a critical case. Using the appropriate  case study template is helpful.

You will find more than one illness in the same patient because of the complications brought about by the actual disease. While it is necessary to include all relevant findings about the patient, you should be specific about the main focus of the study and explain how other illnesses are related to it.

It’s possible that the same case has been studied by other medical professionals before. It could be from another hospital or another country in a different language. Your research will be more effective if you make use of previously published materials. It will help you gain more understanding of the illness and make the necessary preparations to complete the study.

Another easy to gather information by interviewing the patient and the people surrounding this patient. From them, you can get valuable information like habits and vices that the patient may not be willing to share.

Once you have all the data you need, proceed with connecting the relation of one information with another. If your case analysis  is missing something, do another research or conduct another interview until you have the missing piece.

Now that you have all the prices of information together, you can start working on your case study presentation. Make sure to use guides or references to make the task easier and convenient.

Medical case studies are conducted by doctors and focus more on the disease and its treatment. A nursing case study, on the other hand, is conducted by nursing students and licensed nurses. While a nursing case study also includes treatment of the disease, its main focus is on the care of the patient before, during, and after treatment. It is more about making the patient feel at ease throughout the treatment of the disease.

A medical case study is most useful in studying rare diseases with a long latency period. It allows the researcher more time to study how an individual is infected and how the illness manifests. They are also less time consuming compared to actual large scale research.

New information about a known disease can be learned and communicated by medical professionals through a medical case study. That is why even if it is one of the earliest forms of medical communication, the study is still practiced in the present. If you’re learning how to make a medical case study, you will find the samples and templates above useful. You can even download them for free!

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Blog Case Study

How to Present a Case Study like a Pro (With Examples)

By Danesh Ramuthi , Sep 07, 2023

How Present a Case Study like a Pro

In today’s data-driven world, the influence of a well-presented case study can be monumental, making or breaking decisions in boardrooms and classrooms alike. Whether you’re a high-flying executive pitching a groundbreaking initiative or a student aiming to impress a panel of experts, mastering the art of presenting case studies is crucial.

In this article, I delve deep into the nuances of crafting and presenting powerful case studies. From selecting the right metrics to using persuasive narrative techniques, I will cover every element that transforms a mere report into a compelling case study. 

If you are ready to take your case study presentations to the next level then use Venngage’s Case Study Creator to streamline the process or choose from our range of pre-designed case study templates to give your work that professional edge. 

Click to jump ahead: 

What Is a Case Study presentation?

Purpose of presenting a case study, how to structure a case study presentation, how long should a case study presentation be, 5 case study presentation templates, tips for delivering an effective case study presentation, common mistakes to avoid in a case study presentation, how to present a case study faqs.

A case study presentation involves a comprehensive examination of a specific subject, which could range from an individual, group, location, event, organization or phenomenon. This analysis is meticulously organized and presented interactively, with the goal of actively engaging the audience. Unlike a basic report or whitepaper, the purpose of a case study presentation is to stimulate critical thinking among the viewers. 

The primary objective of a case study is to provide an extensive and profound comprehension of the chosen topic. This is achieved through the incorporation of empirical data, expert insights and real-life instances. 

Bold Social Media Business Case Study Template

Case studies act as a social proof for many. The primary purpose of presenting a case study is to offer a comprehensive, evidence-based argument that informs, persuades and engages your audience. Whether you’re a product manager trying to convince your clients or customers to buy the product or in academia explaining the significance of your research findings, a well-executed case study serves multiple objectives.

Firstly, it allows you to delve deep into the intricacies of a specific problem, challenge or opportunity, examining it from various angles. This depth of exploration helps in understanding the issue more holistically.

Secondly, it provides a structured platform to showcase your analytical skills and thought process. A case study enables you to demonstrate how you arrive at conclusions, offering transparency in your decision-making process.

Besides, presenting a case study gives you an opportunity to connect data and real-world scenarios in a compelling narrative. It helps to make your argument more relatable and accessible, increasing its impact on your audience.

One of the contexts where case studies can be very helpful is during the job interview. In some job interviews, candidates may be asked to present a case study as part of the selection process.

This allows the candidate to demonstrate their ability to understand complex issues, formulate strategies, and communicate their ideas effectively.

Case Study Example Psychology

The way you present a case study can make all the difference in how it’s received. A well-structured presentation not only holds the attention of your audience but also ensures that your key points are communicated clearly and effectively.

In this section, we will outline key steps to help you structure your case study presentation for maximum impact.

Let’s get into it. 

Open with an introductory overview 

Start by introducing the subject of your case study and its relevance. Explain why this case study is important and who would benefit from the insights gained. This is your opportunity to grab your audience’s attention.

Explain the Problem in Question

Dive into the problem or challenge that the case study focuses on. Provide enough background information for the audience to understand the issue. If possible, quantify the problem using data or metrics to show the magnitude or severity.

Detail the Solutions to Solve the Problem

After outlining the problem, describe the steps taken to find a solution. This could include the methodology, any experiments or tests performed, and the options that were considered. Elaborate on why the final solution was chosen over the others.

Key Stakeholders Involved

Talk about the individuals, groups, or organizations that were directly impacted by or involved in the problem and its solution. 

Stakeholders may experience a range of outcomes—some may benefit, while others could face setbacks.

For example, in a business transformation case study, employees could face job relocations or changes in work culture, while shareholders might be looking at potential gains or losses.

Discuss the Key Results & Outcomes

Discuss the results of implementing the solution. Use data and metrics to back up your statements. Did the solution meet its objectives? What impact did it have on the stakeholders? Be honest about any setbacks or areas for improvement as well.

Include Visuals to Support Your Analysis

Visual aids can be incredibly effective in helping your audience grasp complex issues. Utilize charts, graphs, images, or video clips to supplement your points. Make sure to explain each visual and how it contributes to your overall argument.

Recommendations and Next Steps

Wrap up by providing recommendations based on the case study findings. Outline the next steps that stakeholders should take to either expand on the success of the project or address any remaining challenges.

Acknowledgments and References

Thank the people who contributed to the case study and helped in the problem-solving process. Cite any external resources, reports, or data sets that contributed to your analysis.

Feedback & Q&A Session

Open the floor for questions and feedback from your audience. This allows for further discussion and can provide additional insights that may not have been considered previously.

Closing Remarks

Conclude the presentation by summarizing the key points and emphasizing the takeaways. Thank your audience for their time and participation, and express your willingness to engage in further discussions or collaborations on the subject.

Blue Simple Business Case Study Template

Well, the length of a case study presentation can vary depending on the complexity of the topic and the needs of your audience. However, a typical business or academic presentation often lasts between 15 to 30 minutes. 

This time frame usually allows for a thorough examination of the case while maintaining audience engagement. Always consider leaving a few minutes at the end for a Q&A session to address any questions or clarify points made during the presentation.

When it comes to presenting a compelling case study, having a well-structured template can be a game-changer. 

It helps you organize your thoughts, data and findings in a coherent and visually pleasing manner. 

Not all case studies are created equal, and different scenarios require distinct approaches for maximum impact. 

To save you time and effort, I have curated a list of 5 versatile case study presentation templates, each designed for specific needs and audiences. 

Here are some best case study presentation examples that showcase effective strategies for engaging your audience and conveying complex information clearly.

1) Medical report case study template

Navigating the healthcare landscape requires meticulous attention to detail, especially when it comes to patient care. 

A well-structured Medical Report Case Study Template is a vital tool in this regard. 

Designed to offer a structured framework for healthcare professionals, this sample template enables you to capture a comprehensive overview of a patient’s medical condition, history and ongoing treatment in an organized, easy-to-understand format.

Medical Report Template

2) Product Case Study Template

A Product Case Study Template can be an invaluable resource for showcasing how your product has solved a particular problem for your customers. 

Structuring this information clearly and concisely helps potential clients understand the value your product can provide.

Product Case Study Template

3) Content marketing case study template

In digital marketing, showcasing your accomplishments is as vital as achieving them. 

A well-crafted case study not only acts as a testament to your successes but can also serve as an instructional tool for others. 

With Coral Content Marketing Case Study Template —a perfect blend of vibrant design and structured documentation, you can narrate your marketing triumphs effectively.

Coral Content Marketing Case Study Template

4) Case study psychology template

Psychological case studies offer invaluable insights into human behavior, cognition and emotion, often serving as foundational pillars in the field of psychology. 

Crafting a comprehensive and impactful psychological case study, however, is a nuanced task that requires meticulous attention to detail, structure and presentation. 

Case Study Psychology Template is here to facilitate this intricate process, allowing you to focus more on content while we handle the formatting and design aspects.

Case Study Psychology

5) Lead generation case study template

Lead generation remains one of the cornerstones for driving business revenue and increasing sales. 

Showcasing your expertise and successful sales tactics through a compelling business case study can serve as a strong validation of your business acumen and methodology. 

Lead Generation Case Study Template is specifically designed to help you create a captivating, data-driven narrative that not only highlights your sales successes but also provides actionable insights for improving future sales strategies.

Modern Lead Generation Business Case Study Presentation Template

Related: 15+ Professional Case Study Examples [Design Tips + Templates]

So, you’ve spent hours crafting the perfect case study and are now tasked with presenting it. Crafting the case study is only half the battle; delivering it effectively is equally important. 

Whether you’re facing a room of executives, academics or potential clients, how you present your findings can make a significant difference in how your work is received. 

Below, I offer essential tips to ensure that your case study presentation is not just informative but also engaging and persuasive. 

  • Know your audience : Tailor your presentation to the knowledge level and interests of your audience. Use language and examples that resonate with them.
  • Rehearse : Rehearsing your case study presentation is essential for a smooth delivery and for ensuring that you stay within the allotted time. Practice helps you fine-tune your pacing, hone your speaking skills with good word pronunciations and become comfortable with the material, leading to a more confident, conversational and effective presentation.
  • Start strong : Open with a compelling introduction that grabs your audience’s attention. You might use an interesting statistic, a provocative question or a brief story that sets the stage for your case study.
  • Be clear and concise : Avoid jargon and overly complex sentences. Get to the point quickly and stay focused on your objectives.
  • Use visual aids : Incorporate slides with graphics, charts or videos to supplement your verbal presentation. Make sure they are easy to read and understand.
  • Tell a story : Use storytelling techniques to make the case study more engaging. A well-told narrative can help you make complex data more relatable and easier to digest.

Gray B2B Content Marketing Case Study Template

With Venngage, you can engage your customers by showcasing your company’s problem-solving approaches, and gain essential knowledge to refine your business plan through Venngage’s case study templates . 

Crafting and presenting a case study is a skillful task that requires careful planning and execution. While a well-prepared case study can be a powerful tool for showcasing your successes, educating your audience or encouraging discussion, there are several pitfalls you should avoid to make your presentation as effective as possible. Here are some common mistakes to watch out for:

Overloading with information

A case study is not an encyclopedia. Overloading your presentation with excessive data, text or jargon can make it cumbersome and difficult for the audience to digest the key points. Stick to what’s essential and impactful.

Lack of structure

Jumping haphazardly between points or topics can confuse your audience. A well-structured presentation, with a logical flow from introduction to conclusion, is crucial for effective communication.

Ignoring the audience

Different audiences have different needs and levels of understanding. Failing to adapt your presentation to your audience can result in a disconnect and a less impactful presentation.

Poor visual elements

While content is king, poor design or lack of visual elements can make your case study dull or hard to follow. Make sure you use high-quality images, graphs and other visual aids to support your narrative.

Not focusing on results

A case study aims to showcase a problem and its solution, but what most people care about are the results. Failing to highlight or adequately explain the outcomes can make your presentation fall flat.

How to start a case study presentation?

Starting a case study presentation effectively involves a few key steps:

  • Grab attention : Open with a hook—an intriguing statistic, a provocative question or a compelling visual—to engage your audience from the get-go.
  • Set the stage : Briefly introduce the subject, context and relevance of the case study to give your audience an idea of what to expect.
  • Outline objectives : Clearly state what the case study aims to achieve. Are you solving a problem, proving a point or showcasing a success?
  • Agenda : Give a quick outline of the key sections or topics you’ll cover to help the audience follow along.
  • Set expectations : Let your audience know what you want them to take away from the presentation, whether it’s knowledge, inspiration or a call to action.

How to present a case study on PowerPoint and on Google slides?

Presenting a case study on PowerPoint and Google Slides involves a structured approach for clarity and impact using presentation slides:

  • Title slide : Start with a title slide that includes the name of the case study, your name and any relevant institutional affiliations.
  • Introduction : Follow with a slide that outlines the problem or situation your case study addresses. Include a hook to engage the audience.
  • Objectives : Clearly state the goals of the case study in a dedicated slide.
  • Findings : Use charts, graphs and bullet points to present your findings succinctly.
  • Analysis : Discuss what the findings mean, drawing on supporting data or secondary research as necessary.
  • Conclusion : Summarize key takeaways and results.
  • Q&A : End with a slide inviting questions from the audience.

What’s the role of analysis in a case study presentation?

The role of analysis in a case study presentation is to interpret the data and findings, providing context and meaning to them. 

It helps the audience understand the implications of the case study, connects the dots between the problem and the solution and may offer recommendations for future action.

Is it important to include real data and results in the presentation?

Yes, including real data and results in a case study presentation is crucial to show experience,  credibility and impact. Authentic data lends weight to your findings and conclusions, enabling the audience to trust your analysis and take your recommendations more seriously

How do I conclude a case study presentation effectively?

To conclude a case study presentation effectively, summarize the key findings, insights and recommendations in a clear and concise manner. 

End with a strong call-to-action or a thought-provoking question to leave a lasting impression on your audience.

What’s the best way to showcase data in a case study presentation ?

The best way to showcase data in a case study presentation is through visual aids like charts, graphs and infographics which make complex information easily digestible, engaging and creative. 

Choose the type of visual that best represents the data you’re showing; for example, use bar charts for comparisons or pie charts for parts of a whole. 

Ensure that the visuals are high-quality and clearly labeled, so the audience can quickly grasp the key points. 

Keep the design consistent and simple, avoiding clutter or overly complex visuals that could distract from the message.

Choose a template that perfectly suits your case study where you can utilize different visual aids for maximum impact. 

Related: 10+ Case Study Infographic Templates That Convert

Knowing how to present a compelling case study can set you apart in the boardroom, classroom or any platform where persuasive communication is key. 

From mastering the structure and nuances of your presentation to avoiding common mistakes, this comprehensive guide has provided you everything you need to impress your audience. 

With the help of Venngage’s Case Study Creator , you’re well-equipped to elevate your case study presentations from ordinary to extraordinary.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

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StatPearls [Internet].

Case study: 33-year-old female presents with chronic sob and cough.

Sandeep Sharma ; Muhammad F. Hashmi ; Deepa Rawat .

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Last Update: February 20, 2023 .

  • Case Presentation

History of Present Illness:  A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound (9 kg) intentional weight loss over the past year. She denies camping, spelunking, or hunting activities. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She admits a cough, shortness of breath, and shortness of breath on exertion.

Social History: Her tobacco use is 33 pack-years; however, she quit smoking shortly prior to the onset of symptoms, six months ago. She denies alcohol and illicit drug use. She is in a married, monogamous relationship and has three children aged 15 months to 5 years. She is employed in a cookie bakery. She has two pet doves. She traveled to Mexico for a one-week vacation one year ago.

Allergies:  No known medicine, food, or environmental allergies.

Past Medical History: Hypertension

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10 mg by mouth every day

Physical Exam:

Vitals: Temperature, 97.8 F; heart rate 88; respiratory rate, 22; blood pressure 130/86; body mass index, 28

General: She is well appearing but anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress causing her to stop mid-sentence.

Respiratory: She has diffuse rales and mild wheezing; tachypneic.

Cardiovascular: She has a regular rate and rhythm with no murmurs, rubs, or gallops.

Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass.

  • Initial Evaluation

Laboratory Studies:  Initial work-up from the emergency department revealed pancytopenia with a platelet count of 74,000 per mm3; hemoglobin, 8.3 g per and mild transaminase elevation, AST 90 and ALT 112. Blood cultures were drawn and currently negative for bacterial growth or Gram staining.

Chest X-ray

Impression:  Mild interstitial pneumonitis

  • Differential Diagnosis
  • Aspiration pneumonitis and pneumonia
  • Bacterial pneumonia
  • Immunodeficiency state and Pneumocystis jiroveci pneumonia
  • Carcinoid lung tumors
  • Tuberculosis
  • Viral pneumonia
  • Chlamydial pneumonia
  • Coccidioidomycosis and valley fever
  • Recurrent Legionella pneumonia
  • Mediastinal cysts
  • Mediastinal lymphoma
  • Recurrent mycoplasma infection
  • Pancoast syndrome
  • Pneumococcal infection
  • Sarcoidosis
  • Small cell lung cancer
  • Aspergillosis
  • Blastomycosis
  • Histoplasmosis
  • Actinomycosis
  • Confirmatory Evaluation

CT of the chest was performed to further the pulmonary diagnosis; it showed a diffuse centrilobular micronodular pattern without focal consolidation.

On finding pulmonary consolidation on the CT of the chest, a pulmonary consultation was obtained. Further history was taken, which revealed that she has two pet doves. As this was her third day of broad-spectrum antibiotics for a bacterial infection and she was not getting better, it was decided to perform diagnostic bronchoscopy of the lungs with bronchoalveolar lavage to look for any atypical or rare infections and to rule out malignancy (Image 1).

Bronchoalveolar lavage returned with a fluid that was cloudy and muddy in appearance. There was no bleeding. Cytology showed Histoplasma capsulatum .

Based on the bronchoscopic findings, a diagnosis of acute pulmonary histoplasmosis in an immunocompetent patient was made.

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe, or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks total. The response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving work of respiration. [1] [2] [3]

Histoplasmosis, also known as Darling disease, Ohio valley disease, reticuloendotheliosis, caver's disease, and spelunker's lung, is a disease caused by the dimorphic fungi  Histoplasma capsulatum native to the Ohio, Missouri, and Mississippi River valleys of the United States. The two phases of Histoplasma are the mycelial phase and the yeast phase.

Etiology/Pathophysiology 

Histoplasmosis is caused by inhaling the microconidia of  Histoplasma  spp. fungus into the lungs. The mycelial phase is present at ambient temperature in the environment, and upon exposure to 37 C, such as in a host’s lungs, it changes into budding yeast cells. This transition is an important determinant in the establishment of infection. Inhalation from soil is a major route of transmission leading to infection. Human-to-human transmission has not been reported. Infected individuals may harbor many yeast-forming colonies chronically, which remain viable for years after initial inoculation. The finding that individuals who have moved or traveled from endemic to non-endemic areas may exhibit a reactivated infection after many months to years supports this long-term viability. However, the precise mechanism of reactivation in chronic carriers remains unknown.

Infection ranges from an asymptomatic illness to a life-threatening disease, depending on the host’s immunological status, fungal inoculum size, and other factors. Histoplasma  spp. have grown particularly well in organic matter enriched with bird or bat excrement, leading to the association that spelunking in bat-feces-rich caves increases the risk of infection. Likewise, ownership of pet birds increases the rate of inoculation. In our case, the patient did travel outside of Nebraska within the last year and owned two birds; these are her primary increased risk factors. [4]

Non-immunocompromised patients present with a self-limited respiratory infection. However, the infection in immunocompromised hosts disseminated histoplasmosis progresses very aggressively. Within a few days, histoplasmosis can reach a fatality rate of 100% if not treated aggressively and appropriately. Pulmonary histoplasmosis may progress to a systemic infection. Like its pulmonary counterpart, the disseminated infection is related to exposure to soil containing infectious yeast. The disseminated disease progresses more slowly in immunocompetent hosts compared to immunocompromised hosts. However, if the infection is not treated, fatality rates are similar. The pathophysiology for disseminated disease is that once inhaled, Histoplasma yeast are ingested by macrophages. The macrophages travel into the lymphatic system where the disease, if not contained, spreads to different organs in a linear fashion following the lymphatic system and ultimately into the systemic circulation. Once this occurs, a full spectrum of disease is possible. Inside the macrophage, this fungus is contained in a phagosome. It requires thiamine for continued development and growth and will consume systemic thiamine. In immunocompetent hosts, strong cellular immunity, including macrophages, epithelial, and lymphocytes, surround the yeast buds to keep infection localized. Eventually, it will become calcified as granulomatous tissue. In immunocompromised hosts, the organisms disseminate to the reticuloendothelial system, leading to progressive disseminated histoplasmosis. [5] [6]

Symptoms of infection typically begin to show within three to17 days. Immunocompetent individuals often have clinically silent manifestations with no apparent ill effects. The acute phase of infection presents as nonspecific respiratory symptoms, including cough and flu. A chest x-ray is read as normal in 40% to 70% of cases. Chronic infection can resemble tuberculosis with granulomatous changes or cavitation. The disseminated illness can lead to hepatosplenomegaly, adrenal enlargement, and lymphadenopathy. The infected sites usually calcify as they heal. Histoplasmosis is one of the most common causes of mediastinitis. Presentation of the disease may vary as any other organ in the body may be affected by the disseminated infection. [7]

The clinical presentation of the disease has a wide-spectrum presentation which makes diagnosis difficult. The mild pulmonary illness may appear as a flu-like illness. The severe form includes chronic pulmonary manifestation, which may occur in the presence of underlying lung disease. The disseminated form is characterized by the spread of the organism to extrapulmonary sites with proportional findings on imaging or laboratory studies. The Gold standard for establishing the diagnosis of histoplasmosis is through culturing the organism. However, diagnosis can be established by histological analysis of samples containing the organism taken from infected organs. It can be diagnosed by antigen detection in blood or urine, PCR, or enzyme-linked immunosorbent assay. The diagnosis also can be made by testing for antibodies again the fungus. [8]

Pulmonary histoplasmosis in asymptomatic patients is self-resolving and requires no treatment. However, once symptoms develop, such as in our above patient, a decision to treat needs to be made. In mild, tolerable cases, no treatment other than close monitoring is necessary. However, once symptoms progress to moderate or severe or if they are prolonged for greater than four weeks, treatment with itraconazole is indicated. The anticipated duration is 6 to 12 weeks. The patient's response should be monitored with a chest x-ray. Furthermore, observation for recurrence is necessary for several years following the diagnosis. If the illness is determined to be severe or does not respond to itraconazole, amphotericin B should be initiated for a minimum of 2 weeks, but up to 1 year. Cotreatment with methylprednisolone is indicated to improve pulmonary compliance and reduce inflammation, thus improving the work of respiration.

The disseminated disease requires similar systemic antifungal therapy to pulmonary infection. Additionally, procedural intervention may be necessary, depending on the site of dissemination, to include thoracentesis, pericardiocentesis, or abdominocentesis. Ocular involvement requires steroid treatment additions and necessitates ophthalmology consultation. In pericarditis patients, antifungals are contraindicated because the subsequent inflammatory reaction from therapy would worsen pericarditis.

Patients may necessitate intensive care unit placement dependent on their respiratory status, as they may pose a risk for rapid decompensation. Should this occur, respiratory support is necessary, including non-invasive BiPAP or invasive mechanical intubation. Surgical interventions are rarely warranted; however, bronchoscopy is useful as both a diagnostic measure to collect sputum samples from the lung and therapeutic to clear excess secretions from the alveoli. Patients are at risk for developing a coexistent bacterial infection, and appropriate antibiotics should be considered after 2 to 4 months of known infection if symptoms are still present. [9]

Prognosis 

If not treated appropriately and in a timely fashion, the disease can be fatal, and complications will arise, such as recurrent pneumonia leading to respiratory failure, superior vena cava syndrome, fibrosing mediastinitis, pulmonary vessel obstruction leading to pulmonary hypertension and right-sided heart failure, and progressive fibrosis of lymph nodes. Acute pulmonary histoplasmosis usually has a good outcome on symptomatic therapy alone, with 90% of patients being asymptomatic. Disseminated histoplasmosis, if untreated, results in death within 2 to 24 months. Overall, there is a relapse rate of 50% in acute disseminated histoplasmosis. In chronic treatment, however, this relapse rate decreases to 10% to 20%. Death is imminent without treatment.

  • Pearls of Wisdom

While illnesses such as pneumonia are more prevalent, it is important to keep in mind that more rare diseases are always possible. Keeping in mind that every infiltrates on a chest X-ray or chest CT is not guaranteed to be simple pneumonia. Key information to remember is that if the patient is not improving under optimal therapy for a condition, the working diagnosis is either wrong or the treatment modality chosen by the physician is wrong and should be adjusted. When this occurs, it is essential to collect a more detailed history and refer the patient for appropriate consultation with a pulmonologist or infectious disease specialist. Doing so, in this case, yielded workup with bronchoalveolar lavage and microscopic evaluation. Microscopy is invaluable for definitively diagnosing a pulmonary consolidation as exemplified here where the results showed small, budding, intracellular yeast in tissue sized 2 to 5 microns that were readily apparent on hematoxylin and eosin staining and minimal, normal flora bacterial growth. 

  • Enhancing Healthcare Team Outcomes

This case demonstrates how all interprofessional healthcare team members need to be involved in arriving at a correct diagnosis. Clinicians, specialists, nurses, pharmacists, laboratory technicians all bear responsibility for carrying out the duties pertaining to their particular discipline and sharing any findings with all team members. An incorrect diagnosis will almost inevitably lead to incorrect treatment, so coordinated activity, open communication, and empowerment to voice concerns are all part of the dynamic that needs to drive such cases so patients will attain the best possible outcomes.

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Histoplasma Contributed by Sandeep Sharma, MD

Disclosure: Sandeep Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.

Disclosure: Deepa Rawat declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

  • Cite this Page Sharma S, Hashmi MF, Rawat D. Case Study: 33-Year-Old Female Presents with Chronic SOB and Cough. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

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The Medical Case Study PowerPoint Template with astonishing backgrounds contains the healthcare industry layouts. This PowerPoint template is special design for professionals and learners in health care industry. Such as, doctors, nurses, pharmaceuticals and other professionals in hospitals and universities who need to present their findings. The PowerPoint has amazing gradient backgrounds and top-quality graphics to easily fill in the details. The medical theme of presentation is an incredible tool for healthcare professionals with designs to display various topics. Further, choose the necessary slides as a part of main presentations. The useful editing features assists users to apply changes in theme colors and organize the template format. View the latest SlideModel PowerPoint medical template of amazing shapes and clip arts.

The Medical Case Study PowerPoint Template is a 10-slide presentation providing variety of infographic layouts. These slides include several icons and clip art PowerPoint shapes relevant to health care industry. For example, the icon of heart rate graph, human heart, stethoscope, first aid and symbols of operation and health insurance. Furthermore, the cliparts include heart plus symbol for aid and angle wings figure use by pharmaceutical companies ad research labs. Therefore, the medical case study PowerPoint is an exclusive template for hospitals and the medical aid and equipment supplier companies. The template of medical case study presents the slides of agenda with four and six sections layout. Moreover, there is a detail introduction template follow by three sections of case study and brilliant heart rate graph timeline.

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medical case study representation

Whereby remains a medical case study read? At the American medical acting series titled House, you can see Dr. House and his crew of doctors do a little huddle and a lot of white scribbling. Now, they’re actually not having a meeting, but they’re conducting a medical case study of their patient. Medical case studies are commonplace for doctors, especially those who are workings in the hospital. Studying the case of apiece patient allows doctors to find the best treatment plan  based on who patient’s condition. So, how does this medical case featured work? Let’s find out.

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Whta Exists a Medical Case Study?

A medizinischen case learning shall an in-depth or thorough research of a health status, particularly those that are rare or illnesses that are elicited differently from the usual. Data gathering and analysis of date play an important role in this learning because it is the does by that doctors and other medical practitioners can correctly diagnose the patient’s condition. Doctors go through trial and blunder before an actual diagnosis is decided. There are risks in a sample and error process; that is why the benefits should always outweigh the risks when itp is made. An focus of a medical case research is at the identification real treatment of a known oder non disease. Before an case is put into writing, a brainstorming session between the members of the medical crew takes place. This is where the exchange of information and the realization out the data gathered is used.

And information gathered for a medical dossier study is biological. They are information about the patient’s past real presentational day-to-day activities. The methods used in adenine lawsuit study live determined through research. Different methods are essential in one study because it helps in making suitable building for the case. Medical case studies greatly help in furthering who knowledge of doctors or other medical professionals in their field of expertise. It has a study material that applies both medical theory real actual habit. Similar case studies include a  nursing case investigate and a patient case studies .

How to Produce a Medical Rechtssache Examine

A medical case study requires time, patience, and a lot of knowledge for the case toward handheld. Formatting the study is simple. The difficult part is putting together all of the information gathered and make more use out of it that will help find adenine service for one patient’s illness. To related you prepare your medical case research, here are a few steps that will help you get started.

1. Find Your Case Study Type

Base the design, style, and sizing of your case study according to yours audience or readers. Employing the audience’s references over their style will help them effectively understand the medical lecture, especially if it is about a critical case. Using the appropriate  case study template are helpful.

You will find more than one illness in who same patient because of the complicated brought about by the actual illness. While it shall essential on include all relevant findings about an patient, you should be specific about the main focus of the student and explain how other illnesses exist related to it. Learn how to use the care management app to coordinate safe and effectual grooming for patients.

3. Study Similar Posted Materials

It’s possibles which the equal case has been studied by other medical professionals before. It was be from another hospital or another country included a varied language. Owner research will be more highly if you make use of previously published materials. It will help you gain see insight of the illness and make the necessary preparations to complete the study.

4. Conduct Press

Another easy to gather information by interviewing the become and the people surrounding this patient. From them, you can get valuable information like habits and vices is the patient may not be willing to share. Customer and Partner Achieve Stories | Microsoft Azure

5. Analyze Data

Once them have all the data yours need, proceed with connecting the relation of one information on another. If your case analysis  is missing something, do more research instead conduct another interview until it possess the missing piece.

6. Write Your Case Study Web

Currently that you have all the prices of information together, it may start working on your case learning presentation. Make save up exercise guides conversely references to make the task easier and convenient. Case Studies – Microsoft Adopt

What is the difference between adenine arzt kasten study and a breast sache study?

Medizinisch rechtssache studies is conducted by doctors and focus more on the disease and its treatment. A nursing case study, on and other hand, is directed by nursing students furthermore licensed nurses. While adenine nursing case study also includes treatment starting the disease, its main focus be on the care of the patient for, during, and after treatment. It has more about making the patient perceive at ease throughout the treatment of to disease. Download our Case Report presentation templates for Google Slide real PPT and create effective medical presentations ✓ Loose ✓ Easy to edit ...

What are an advantages of a medical case study?

A general case study the most useful in student rare illness at a long latency period. Thereto allows who researcher more time to study how an individual is infected additionally wherewith the illness reveals. They are also less time consuming compared to actual large scale research. Free Medical Google Slides themes and PowerPoint templates

Recent information about a known disease bottle be learned and communicated by medical technical through one medizin case study. That is why even if computers is individual starting the your forms of medical community, the study is still practiced in the present. If you’re learning how to take a medical case study, you will find the samples and templates above useful. You able even download them for free! Available presentation templates | Microsoft Create

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medRxiv

Large language models in simplifying radiological reports: systematic review

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Objectives Simplifying medical information to make it understandable for patients, specifically in the case of radiology reports, is challenging. It requires time and effort from medical personnel. This systematic review focuses on the application of large language models (LLMs) in generating simplified radiological imaging reports, as well as answering patient inquiries regarding radiological procedures. Materials and Methods The authors searched for studies published up to January 2024. Search terms focused on LLMs generated simplified radiological reports and answers to patient inquiries regarding radiological procedures. MEDLINE was used as a search database. Results Overall, eight studies published between May 2023 and November 2023 were included. All studies showed that LLMs can produce simplified medical information for patients. Four studies (50%) used GPT-3.5, Two studies (25%) conducted a comparative analysis between GPT-3.5 and GPT-4. One study (12.5%) examined Microsoft Bing. One study (12.5%) utilized GPT-4. Four studies (50%) used LLMs to simplify radiological reports. Four studies (50%) used LLMs to answer patient questions regarding radiological procedures. Only two studies (25%) used patients to evaluate the LLMs output. One study (12.5%) compared their initial prompt with optimized prompt. Five studies (62.5%) showed missing, inaccurate and potentially harmful AI outputs. Conclusion LLMs can be used to simplify medical imaging reports and procedures, for improved patient comprehension. However, their limitations cannot be ignored. Further study in this field is essential and more conclusive evidence is needed.

Competing Interest Statement

The authors have declared no competing interest.

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This study did not receive any funding

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Factor structure of psychosis screening questionnaire in Ugandan adults

  • Claire Kwagala 1 ,
  • Amantia Ametaj 2 ,
  • Hannah H. Kim 3 ,
  • Joseph Kyebuzibwa 1 ,
  • Rogers Okura 1 ,
  • Anne Stevenson 2 , 4 , 6 ,
  • Bizu Gelaye 2 , 5 &
  • Dickens Akena 1  

BMC Psychiatry volume  24 , Article number:  36 ( 2024 ) Cite this article

Metrics details

Psychotic disorders are common and contribute significantly to morbidity and mortality of people with psychiatric diseases. Therefore, early screening and detection may facilitate early intervention and reduce adverse outcomes. Screening tools that lay persons can administer are particularly beneficial in low resource settings. However, there is limited research evaluating the validity of psychosis screening instruments in Uganda. We aimed to assess the construct validity and psychometric properties of the Psychosis Screening Questionnaire (PSQ) in Uganda in a population with no history of a psychotic disorder.

The sample consisted of 2101 Ugandan adults participating as controls in a larger multi-country case-control study on psychiatric genetics who were recruited between February 2018 and March 2020. Participants were individuals seeking outpatient general medical care, caretakers of individuals seeking care, and staff or students recruited from five medical facilities that were age 18 years or older and able to provide consent. Individuals were excluded who had acute levels of alcohol or substance use, including being under inpatient hospitalization or acute medical care for one of these conditions. We used confirmatory factor analysis (CFA) and item response theory (IRT) to evaluate the factor structure and item properties of the PSQ.

The overall prevalence screening positive for psychotic symptoms was 13.9% 95% CI (12.4,15.4). “Strange experiences” were the most endorsed symptoms 6.6% 95% CI (5.6,7.8). A unidimensional model seemed to be a good model or well-fitting based on fit indices including the root mean square error of approximation (RMSEA of 0.00), comparative fit index (CFI of 1.000), and Tucker-Lewis Index (TLI of 1.000). The most discriminating items along the latent construct of psychosis were items assessing thought disturbance followed by items assessing paranoia, with a parameter (discrimination) value of 2.53 and 2.40, respectively.

The PSQ works well in Uganda as an initial screening tool for moderate to high-level of psychotic symptoms.

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Introduction

Psychotic disorders, including schizophrenia spectrum and bipolar affective disorders, are chronic severe mental illnesses that contribute significantly to high morbidity (years lived with disability) and mortality, mainly due to suicide risk [ 1 ]. Moreover, studies have demonstrated that people with psychotic disorders have an increased risk of cardiovascular disease [ 2 ], metabolic syndrome [ 3 ] and diabetes mellitus [ 4 ], which all predict premature mortality and can negatively impact quality of life [ 5 ].

The prevalence of psychotic disorders has been shown to vary widely worldwide with estimates between 0.8 and 31.4% [ 6 ]. However, many people have psychotic symptoms without a psychotic disorder and these too are associated with significant distress and impairment in personal, family, social, educational, occupational, and other important areas of life [ 7 ]. Research points to a higher prevalence of psychotic symptoms among individuals from low-resource settings [ 7 ]. For example, a study done in Dar-es-Salaam, Tanzania, showed the prevalence of psychotic symptoms to be 3.9% [ 8 ], and in another in a rural Kenyan setting, the prevalence of psychotic symptoms was found to be 8.1% [ 9 ].

Early screening for psychosis may facilitate early detection and prompt treatment for high-risk populations. In low-resource settings like Uganda, with a small number of mental health practitioners, screening tools that laypersons can administer are needed [ 10 , 11 ]. Several instruments have been used to assess and screen for psychotic disorders, including self-report questionnaires, such as the Psychosis Screening Questionnaire (PSQ). Assessing the psychometric properties of PSQ in the Ugandan setting would help screen high-risk populations for psychosis, which could then be followed up with a diagnostic assessment.

The PSQ is preferred by clinicians and researchers because of its brevity and reliability and has been used with ethnic and cultural minorities in high-income countries. The PSQ was tested for equivalence in the United Kingdom in a study across five different ethnic groups in reporting psychotic symptoms [ 12 ]. It has also been adopted and used in Kenya [ 9 ], Tanzania [ 8 ] and Ethiopia [ 13 ].

There have been no studies in Uganda to date, to our knowledge, that examine the psychometric properties of the PSQ outside of our group. Our group has published a cross-cultural examination of the PSQ across Uganda, Ethiopia, Kenya, and South Africa [ 1 ]. However, this prior study was focused on a broad comparison of the scale’s performance across the four countries to test its equivalence across settings, without focusing on the specifics of the performance of PSQ from each country. The goal of this study was to examine the performance of PSQ in Uganda in depth, including fine grained analyses at the item level to understand its cultural relevance for the setting. Therefore, this study aimed to investigate the construct validity of the PSQ by exploring factor structure and item properties through item response theory analyses in Uganda with adults from a general medical setting.

We utilized data from the Neuropsychiatric Genetics of African Populations-Psychosis (NeuroGAP-Psychosis) study in Uganda, Ethiopia, Kenya, and South Africa. NeuroGAP-Psychosis is a case-control study aimed at expanding the understanding of genetic and environmental risk factors for psychotic disorders across different African populations, for the purposes of the current study, we analyzed data from Uganda only.

Participants and study procedure

Study participants for the current study consisted of participants without psychosis (i.e., controls) in Uganda who were recruited between February 2018 and March 2020. Participants were individuals seeking outpatient general medical care, caretakers of individuals seeking care, and staff or students working at general medical facilities. Only controls were included in this study because patients with clinical diagnoses of psychosis (i.e., cases) were not administered the PSQ. Participants were recruited from the following medical facilities: Butabika National Mental Health Referral Hospital, Naguru, Arua, Mbarara, and Gulu Regional Referral Hospitals. Inclusion criteria for controls were age 18 years or older and able to provide consent. Individuals were excluded who had acute levels of alcohol or substance use, including being under inpatient hospitalization or acute medical care for one of these conditions. Ethical approval was obtained from all participating sites, including the Makerere University School of Medicine Research and Ethics Committee (SOMREC #REC REF 2016-057), the Uganda National Council for Science and Technology (UNCST #HS14ES), and the Harvard T.H. Chan School of Public Health (#IRB17-0822).

Psychosis screening questionnaire

The presence of psychosis was assessed using the Psychosis Screening Questionnaire (PSQ), a self-reported brief screening instrument designed to detect psychotic symptoms. The PSQ has five primary (root) questions that assess the presence of psychotic symptoms: mania, thought-interference, paranoia, strange experiences, and hallucinations. Endorsement of any of the primary questions are followed by one to two secondary questions to further screen for psychotic experiences. The original PSQ assesses symptoms in the past year, but for our purposes we focused on lifetime symptoms “ever” in one’s life. We derived a binary response (0 = negative; 1 = positive) for each of the five psychotic symptoms based on responses to PSQ questions. In addition to the five binary responses, we derived a composite screening measure across the five symptoms. Presence of psychotic experiences was defined if positive on of any individual symptoms on the measure.

Data analysis plan

Standard sociodemographic variables were collected, including age, sex at birth, level of education, marital status, and current living situation. Participant characteristics were described using means and standard deviation for continuous variables and counts and percentages for categorical variables. Prevalence estimates of psychotic symptoms were also calculated. All study participants from Uganda were included in all analyses, but three individuals from the total sample had missing data on the PSQ and were excluded from the below listed analyses.

Confirmatory factor analysis

We examined the construct validity and factor structure of the PSQ by conducting confirmatory factor analysis (CFA) in Mplus 8 v.1.7. We tested a unidimensional factor structure based on past research and theory for the measure [ 14 ] including a study that reported one latent factor on a multi-ethnic British sample comparing PSQ’s equivalence across groups [ 12 ]. A split sample exploratory factor analysis was not possible due to a floor effect in our sample of controls with a low prevalence of psychotic disorders. Our model fit was calculated with a weighted least square mean and variance adjusted (WLSMV) estimator for categorical data, and measurement error was not assumed to be correlated among items.

CFA model fit was evaluated with the following goodness-of-fit metrics: (1) root mean square error of approximation (RMSEA) of 0.060 or below [ 15 ]; (2) comparative fit index (CFI) of 0.95 or above [ 15 , 16 ]; and (3) Tucker-Lewis index (TLI) of 0.95 or above [ 15 ].

Item response theory

The study further explored the factorial validity of the PSQ for Ugandan adults with item response theory (IRT) to better understand the relationship between the latent trait of psychosis and items on the PSQ. IRT accounts for how each item measures the latent construct and individual variation across the construct’s severity levels. IRT uses two main parameters, item discrimination and item difficulty, to describe the relationship between the participant, the latent construct (psychosis), and each PSQ item. The discrimination (or α) parameter describes the ability of each item to distinguish between degrees of psychotic symptom severity. The item difficulty (or b ) indicates the location along the psychosis latent construct at which individuals have a ≥ 50% likelihood of endorsing a particular item.

We examined the assumptions required for an IRT model: unidimensionality, local independence, and monotonicity. The unidimensionality assumption was assessed by examining a one-factor CFA model, while the monotonicity was investigated via Mokken scaling analysis. After checking the assumptions, a 2-Parameter Logistic model was fitted using a unidimensional latent structure. Item information curves (IICs), item characteristic curves (ICCs), and the total information curves were generated using the R statistical program, version 3.6.2, packages Mokken and ltm.

Demographic characteristics

The final analytic population consisted of 2,104 adults (Table  1 , includes three individuals with missing data), with more participants who identified as female (56%) than male (44%). A large proportion of the participants were between the ages of 30 and 44 (40%), and a majority reported being married or cohabiting with a partner (53%). In addition, 42% reported attending at least some secondary school, and 32% reported finishing primary school.

The overall prevalence of individuals screening positive for at least one psychotic symptom in their lifetime in our sample was 13.9% 95%CI (12.4, 15.4). Strange experiences was the most endorsed item 6.6% 95% CI (5.6, 7.8), followed by paranoia 5.1% 95%CI (4.2, 6.1), hallucinations 4.9% 95% CI (4.0, 5.9), and thought interference 4.1% 95% CI (3.3, 5.0). Mania was the least endorsed symptom 1.4% 95% CI (0.9, 2.0) (Fig.  1 ).

figure 1

Prevalence of positive screen items on PSQ in Uganda (n = 2,101)

We carried out a confirmatory factor analysis to examine the construct validity and factorial structure of the PSQ to assess model fit for a unidimensional model. The model fit indices and standardized factor loadings of each item are presented in Table  2 . Indicators of goodness of fit, including RMSEA, CFI, and TLI indicate excellent fit (RMSEA of 0.00, TLI of 1.000 and CFI of 1.000) for a unidimensional model of the PSQ. The perfect model fit for categorical data was likely due to skewed binary indicators (i.e., floor effect) where we did not have sufficient power to reject the null model (Hu & Bentler, 1999; Methuen, 2014). Furthermore, all items loaded strongly (ranging from 0.72 to 0.79) on the unidimensional model of PSQ and provided additional evidence for a good model fit. The item with the weakest loading on the factor, although still strong, was mania (0.72).

The IRT discrimination (α) and difficulty ( b ) parameters for each of the five PSQ items are presented in Table  3 , and the IICs, ICCs, and test information function curves are found in Fig.  2 . The most discriminating items along the latent construct were thought disturbance followed by paranoia, with a parameter (discrimination) values of 2.53 and 2.40, respectively. This is shown visually in the item information curves (Fig.  2 a), where thought disturbance has the highest peak, followed by paranoia. Therefore, these two items (thought disturbance and paranoia) might best discriminate between participants with higher levels of psychotic experiences severity and participants with lower levels of psychotic experiences severity. The least discriminating item was strange experiences ( \( \alpha =2.53\) ), indicating that this item does not discriminate as effectively between participants at high and low levels of psychotic experiences relative to the other items. Overall, the items tend to discriminate between participants showing higher levels of psychotic experiences severity, given that the item information function peaks at the upper level of the latent construct (Fig.  2 c). The test information function indicates that the PSQ is useful for screening moderate to high levels of psychotic symptoms rather than average or below-average levels.

figure 2

( a - c ): Item Response Theory −  2a (Item Characteristic Curves), 2b (Item Information Curves, and 2c (Test Information Function)

The ICCs visually represent the probability of endorsing items by the underlying construct severity (Fig.  2 b). The ICC plot indicates that the probability of endorsing mania is highest when a person’s psychotic experience severity is high. In contrast, the other four items are similar in their probability of being endorsed at slightly moderate psychotic experiences levels, with strange experiences being the least difficult.

This study was one of the first to examine the psychometric properties of the PSQ in a Ugandan sample. The lifetime prevalence of psychotic symptoms in our sample was 13.9%, with strange experiences as the most endorsed item with a prevalence of (6.6%) and mania as the least endorsed symptom (1.4%). All items loaded strongly (ranging from 0.72 to 0.79) on a single psychosis latent factor measured by the PSQ and provided evidence for a good model fit. The IRT analysis indicated that the PSQ may provide more information for higher-than-average psychosis levels and that the PSQ will more likely identify individuals with a high level of psychosis compared to those with low levels.

Given that our study was one of the first of its kind in Uganda, the prevalence of lifetime psychotic symptoms of 13.9% found in our study cannot be compared with previous research in Uganda. The only other study in Uganda that used the PSQ outside of our reports from the NeuroGAP-Psychosis study noted a prevalence of 63% in first psychosis episode patients at Butabika National Psychiatric Referral Hospital [ 17 ]. However, this study does provide an adequate comparison since it was based on a retrospective chart review of people presenting for the first time specifically for mental health disorders while our study consisted of people with no history of psychotic disorders. In a study done in a Chinese adult population found a lifetime prevalence estimate of 5.5% for positive screens on the PSQ for the first phase of their study [ 18 ]. This is lower than the one found in our setting, and this could potentially be due to cultural differences and the different meanings attached to the different psychotic symptoms between the two settings.

On the confirmatory analysis, the PSQ performed well as a unidimensional construct. These findings are aligned with prior theory and research on the PSQ in high-income countries [ 7 , 12 ]. IRT analyses showed that the most discriminating items along the latent construct were thought disturbance followed by paranoia, and these items gave the most precise information regarding psychosis. This finding is comparable to a study on psychotic symptoms in the United Kingdom examining diverse ethnic groups, which showed that paranoid symptoms were the most endorsed for participants of Caribbean ancestry [ 12 ].

Strange experiences, on the other hand, was the least precise symptom for identifying positive screens compared to other items. Given that the strange experiences item was the least discriminating item for psychosis and was the most endorsed, this item may not work well to screen for psychosis in Uganda. One explanation may be the description of a strange experience varies with different cultures in Uganda, with many experiences that would be considered strange being normalized due to the popular belief in supernatural experiences such as communication with the gods [ 19 , 20 ]. Therefore, the prevalence proportion of 13.9% may have been overinflated by the strange experiences item.

Overall, the IRT analysis indicates that the PSQ provides valuable information about psychosis as a construct at higher levels of the latent trait, thus more accurately detecting moderate to severe levels of psychosis. The PSQ may be used by health care providers in busy clinics (due to its brevity) as well as by trained lay (community) health care workers to routinely screen for psychosis in primary health care facilities as well as community settings respectively. In low resourced settings, the PSQ provides a gateway to provision of care to persons with psychoses; screen positive case can always be referred to mental health care providers for a detailed diagnostic assessment. The measure may be less adept as a screen in generalist settings such as a screen administered to all primary care patients.

Limitations

This study should be understood within its limitations. One major limitation is the lack of evaluation of measurement invariance analysis by key demographic (e.g., sex at birth) and clinical characteristics due to the low prevalence of psychotic experiences. Another limitation is the inability to conduct sub-group analyses due to few screen positive cases. The PSQ was not validated against a gold standard tool, this is a limitation of the design of our study given that the tool is from a neuropsychiatric and genetic study that aimed to reduce participant burden. Future research examining the PSQ against a clinical gold standard measure will shed further light on the measure’s utility in Uganda. In addition, future studies in this area may also consider using other self-report measures of psychosis to establish if the PSQ accurately measures the dimension of psychosis.

Recall bias was another important limitation in this study. This was again due to the study design that was aimed at capturing positive psychotic screens across the lifetime but that we are aware that most participants are likely reporting from more recent experiences.

We did not do rephrasing and item equivalence for “strange experiences” which was the least discriminating item. This is an important area of future research.

We did not use additional measures, such as the positive symptom scale of PANSS, to establish convergent and discriminant validity. We recommend that future studies in this area consider employing such measures to further validate the Psychotic Screening Questionnaire.

In this study, we only recruited participants in general hospital settings, and therefore the findings may not be generalizable to other populations. However, study strengths include administering and evaluating the PSQ in an understudied population using a large sample size.

This is one of the first study to assess the psychometric properties of the Psychosis Screening Questionnaire in a Ugandan population to the best of our knowledge. This study estimated a lifetime prevalence of psychotic symptoms at 13.9% in a population with no history of a psychosis spectrum disorder, with strange experiences as the most endorsed symptom. Our findings show good construct validity and a one-dimensional structure for the PSQ in Uganda. The measure may be adept at screening individuals with higher levels of psychosis and be more helpful when administered to individuals displaying mental health symptoms for further diagnostic assessment.

Recommendations

Future studies should validate the PSQ against gold standard measures such as the PANSS. Furthermore, there is need to examine the criterion validity of the PSQ in a large sample of participants so that sub-group analyses can be conducted.

Data availability

All data will be deposited and made available through the National Institute of Mental Health Data Archive at this site: https://nda.nih.gov/edit_collection.html?id=3805 .

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Acknowledgements

The authors would like to thank the participants who took part in the NeuroGAP-Psychosis study who made this work possible. We would also like to thank the Ugandan NeuroGAP-Psychosis research assistants: Adiru Tamali, Apio Racheal, Clare Samba Nalwoga, Francis Ojara, Julius Okura, Naome Nyinomugisha, Samalie Nsangi, Stanley Baniyo, and Stella Anena.

This research was funded by the Stanley Center for Psychiatric Research at Broad Institute of MIT and Harvard. BG and DA are supported in part by the United States’ National Institute of Mental Health (grant R01MH120642). AS and BG are supported in part by NIMH U01MH125045. AAA’s time was supported by NIMH T32MH017199.

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Authors and affiliations.

Department of Psychiatry, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda

Claire Kwagala, Joseph Kyebuzibwa, Rogers Okura & Dickens Akena

Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA

Amantia Ametaj, Anne Stevenson & Bizu Gelaye

Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, MA, USA

Hannah H. Kim

Stanley Center for Psychiatric Research at Broad Institute of MIT and Harvard, Cambridge, MA, USA

Anne Stevenson

The Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA

Bizu Gelaye

Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

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Contributions

DA and BG conceived and designed the study. CK, AA and HK undertook statistical analyses. CK, AA, and BG drafted the manuscript. All authors CK, AAA, HHK, JK, OK, AS, BG and DA interpreted the data, critically revised the draft for important intellectual content and gave final approval of the manuscript to be published.

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Correspondence to Claire Kwagala .

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Ethics approval and consent to participate.

All experiments and procedures involving human subjects were conducted in accordance with the ethical guidelines and principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Makerere University School of Medicine Research and Ethics Committee (SOMREC #REC REF 2016-057), the Uganda National Council for Science and Technology (UNCST #HS14ES), and the Harvard T.H. Chan School of Public Health (#IRB17-0822). All participants provided informed consent prior to partaking in the study. All participants were read aloud the full consent form in the language of their preference by a study team member. All participants gave informed consent prior to partaking in the study through either writing their signature on the consent form or in the case of illiterate participants, by providing their fingerprint. The participants that screened positive were referred to the appropriate mental health services.

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Kwagala, C., Ametaj, A., Kim, H.H. et al. Factor structure of psychosis screening questionnaire in Ugandan adults. BMC Psychiatry 24 , 36 (2024). https://doi.org/10.1186/s12888-023-05485-2

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Received : 01 June 2023

Accepted : 28 December 2023

Published : 09 January 2024

DOI : https://doi.org/10.1186/s12888-023-05485-2

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  • Psychosis screening questionnaire (PSQ)
  • Psychometrics
  • Construct validity
  • Confirmatory Factor Analysis (CFA)
  • Item response theory (IRT)

BMC Psychiatry

ISSN: 1471-244X

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