Case Reports: Style and Formatting

Two additional articles in our case report series discuss terminology and phrasing in biomedical case reports that are often confused/misused or unique. In this article, we discuss small stylistic and formatting touches that may help to increase the clarity of these reports.

Download our free resource on terminology and phrasing in clinical case reports.

He/she: When a single patient is being described in a case report, it is common to write “he” or “she” after initially introducing the patient. However, the use of vague pronouns may be confusing to the reader, as in these examples:

• The patient was a 55-year-old female with a history of fainting. The attending physician performed a physical examination and ordered laboratory testing. She had high levels of blood glucose and hypercholesterolemia.
• The patient was a 55-year-old female with a history of fainting. A physical examination and laboratory testing were performed at admission. Blood screening revealed hypercholesterolemia. High levels of blood glucose were also noted. She was admitted to our department for further testing.

In the first case, although it may be inferred that “She” refers to the patient rather than to the doctor, “The patient” would be preferable for clarity. In the second example, the several-sentence separation between the description of the patient and the pronoun “She” may be disorienting. Again, “The patient” may be a better option. As in grant proposals, remember that your reader (whether an editor or a fellow researcher) may be distracted or inattentive. Therefore, try to reduce ambiguity wherever possible.

Doses/dosages: Doses and dosages may be placed before or after a drug name, but either format should be applied consistently, as in “100 mg/kg/day ampicillin and 50 mg/kg/day penicillin were studied” or “ampicillin 100 mg/kg/day and penicillin 50 mg/kg/day were studied.”

Clinical testing: Authors will sometimes list clinical tests and results using sentence fragments, as might be done in a patient's medical chart. However, narrative form may be more comprehensible, especially when read by a researcher in a different field:

• Laboratory testing. Cholesterol levels high, 300 mg/dL. Other tests negative. (Less clear)
• Laboratory testing was performed. The patient's cholesterol levels were high (300 mg/dL). All other tests yielded negative results. (More clear)

Levels: Professional editors will often add the word level(s) or concentration to enhance the clarity of biomedical writing:

• The patient's hemoglobin was normal. (Less clear)
• The patient's hemoglobin levels were normal. (More clear)

In the first example, although “levels” is implied and the phrasing is common, the sentence suggests that the protein itself was normal (e.g., no mutations), rather than its concentration. Adding “levels” in the second example thus improves the accuracy of the statement.

We hope that our last three editing tips will be useful as you write case reports. Please email us at [email protected] if you have any questions or comments. We wish you the best in your research and writing!