Writing a Case Report

What is a case report?
"A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine. Some reports contain an extensive review of the relevant literature on the topic. The case report is a rapid short communication between busy clinicians who may not have time or resources to conduct large scale research."
Components of your case report
Different journals may have different formats or variations for case reports, so you should look at other case reports published in the journal you are submitting to; the journal may also have detailed instrutions on their site.

If you are writing a case report for the Case Management class, use the following format for your paper:

Title of paper, author name and date of submission
Make sure to include the words case report in your title
Background: Literature review
  • AOM literature review
  • Biomedicine literature review: The next part of your paper will be a Background section. Find a Western research article that is related to the patient’s chief complaint, (You could also research their medications or a surgery, a genetic condition, etc.) and one from a TCM perspective relating to the any aspect of your diagnosis or treatment. Briefly summarize and include your findings in the background area of your paper. Find research that is meaningful to your paper. You will use superscript and cite your research in AMA format in the end of your paper in a area titled “references or citations”.
Don't know what a Literature Review is? Watch the "Get Lit" video for a better understanding of what this section should look like.
  • Age, gender, and occupation
  • Total number of treatments and how many treatments have been provided by you
  • Chief complaint(s)
    • Date of onset and causes
    • OPQRST and associated symptoms
    • Previous AOM treatments and results
    • Relevant “Ten Questions”
  • Western Medical diagnosis and treatments
    • Surgeries
    • Relevant health history
    • Medications, and why they are taking the medications. Include dosages
    • Relevant Family history
    • Lifestyle details: diet, exercise, history of smoking or drug use
  • Brief physical description
  • Vital signs (BP, HR, height, weight)
  • Tongue, pulse, finding from palpation
  • Other supplemental data
Outcome Assessment Tools
  • Range of Motion
  • Orthopedic tests
  • MYMOPS, VAS, etc
  • Use a specific OAT appropriate to the patient’s chief complaint
  • Working diagnosis and pattern
    • TCM disease diagnosis (bian bing)
    • TCM Pattern differentiation (bian zheng)
    • Validating signs and symptoms (no chart this time)
    • Explanation of contradictory signs and symptoms. Distinction between root and branch diagnoses if necessary
Treatment Principles and procedures
  • Treatment principles (based on diagnosis)
  • Treatment method (e.g. acupuncture, moxa, etc.)
  • Points prescription with needle stimulation method.(e.g. Warm needle on ST 36, Lifting, and thrusting on GB 20 until muscle fasciculated, even technique on PC 6. You can use symbols + tonifying, - reducing, = even.)
  • Herbal prescriptions/formulas with dosages (e.g. Xiao Yao Wan tea pills, 8 pills TID.)
  • Patient education and recommendations or referrals
Plan and Prognosis
  • Treatment plan
  • Focus of treatment
  • Short and long term goals
Prognosis Results/discussion
  • Outcome measurement changes (compare the change between the first time you used your outcome measurement tool and the last time)
  • Compliancy with herbs
  • Frequency of treatment maintained
  • Closing discussion
  • Cite your research articles in AMA format
What IS a Literature Review?

OK. You’ve got to write a literature review. You dust off a novel and a book of poetry, settle down in your chair, and get ready to issue a “thumbs up” or “thumbs down” as you leaf through the pages. “Literature review” done. Right?

Wrong! The “literature” of a literature review refers to any collection of materials on a topic, not necessarily the great literary texts of the world. “Literature” could be anything from a set of government pamphlets on British colonial methods in Africa to scholarly articles on the treatment of a torn ACL. And a review does not necessarily mean that your reader wants you to give your personal opinion on whether or not you liked these sources.

What is a literature review, then?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper is likely to contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper’s investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Who writes these things, anyway?

Literature reviews are written occasionally in the humanities, but mostly in the sciences and social sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a literature review is written as a paper in itself.

Not sure what a literature review is? Check out this really wonderful lecture by Dr. Candace Hastings, Director of Texas A&M's University Writing Center.
Writing a Literature Review
Let’s get to it! What should I do before writ


If your assignment is not very specific, seek clarification from your instructor:

  • Roughly how many sources should you include?
  • What types of sources (books, journal articles, websites)?
  • Should you summarize, synthesize, or critique your sources by discussing a common theme or issue?
  • Should you evaluate your sources?
  • Should you provide subheadings and other background information, such as definitions and/or a history?

Find models

Look for other literature reviews in your area of interest or in the discipline and read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. You can simply put the word “review” in your search engine along with your other topic terms to find articles of this type on the Internet or in an electronic database. The bibliography or reference section of sources you’ve already read are also excellent entry points into your own research.

Narrow your topic

There are hundreds or even thousands of articles and books on most areas of study. The narrower your topic, the easier it will be to limit the number of sources you need to read in order to get a good survey of the material. Your instructor will probably not expect you to read everything that’s out there on the topic, but you’ll make your job easier if you first limit your scope.

And don’t forget to tap into your professor’s (or other professors’) knowledge in the field. Ask your professor questions such as: “If you had to read only one book from the 90’s on topic X, what would it be?” Questions such as this help you to find and determine quickly the most seminal pieces in the field.

Consider whether your sources are current

Some disciplines require that you use information that is as current as possible. In the sciences, for instance, treatments for medical problems are constantly changing according to the latest studies. Information even two years old could be obsolete. However, if you are writing a review in the humanities, history, or social sciences, a survey of the history of the literature may be what is needed, because what is important is how perspectives have changed through the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is currently of interest to scholars in this field and what is not.

Strategies for writing the literature review

Find a focus

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Convey it to your reader

A literature review may not have a traditional thesis statement (one that makes an argument), but you do need to tell readers what to expect. Try writing a simple statement that lets the reader know what is your main organizing principle. Here are a couple of examples:

  • The current trend in treatment for congestive heart failure combines surgery and medicine.
    More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You’ve got a focus, and you’ve stated it clearly and directly. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories

Just like most academic papers, literature reviews also must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. The following provides a brief description of the content of each:

  • Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern.
  • Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each).
  • Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed?

Organizing the body

Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further.

To help you come up with an overall organizational framework for your review, consider the following scenario:

You’ve decided to focus your literature review on materials dealing with sperm whales. This is because you’ve just finished reading Moby Dick, and you wonder if that whale’s portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980’s. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick, so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel.

Now consider some typical ways of organizing the sources into a review:

  • Chronological: If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus.
  • By publication: Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies.
  • By trend: A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.
  • Thematic: Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a “chronological” and a “thematic” approach is what is emphasized the most: the development of the harpoon or the harpoon technology.But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as “evil” in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.
  • Methodological: A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the “methods” of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.
    Once you’ve decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

  • Current Situation: Information necessary to understand the topic or focus of the literature review.
  • History: The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
  • Methods and/or Standards: The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research: What questions about the field has the review sparked? How will you further your research as a result of the review?

Begin composing

Once you’ve settled on a general pattern of organization, you’re ready to write each section. There are a few guidelines you should follow during the writing stage as well. Here is a sample paragraph from a literature review about sexism and language to illuminate the following discussion:

  • However, other studies have shown that even gender-neutral antecedents are more likely to produce masculine images than feminine ones (Gastil, 1990). Hamilton (1988) asked students to complete sentences that required them to fill in pronouns that agreed with gender-neutral antecedents such as “writer,” “pedestrian,” and “persons.” The students were asked to describe any image they had when writing the sentence. Hamilton found that people imagined 3.3 men to each woman in the masculine “generic” condition and 1.5 men per woman in the unbiased condition. Thus, while ambient sexism accounted for some of the masculine bias, sexist language amplified the effect. (Source: Erika Falk and Jordan Mills, “Why Sexist Language Affects Persuasion: The Role of Homophily, Intended Audience, and Offense,” Women and Language19:2).

Use evidence

In the example above, the writers refer to several other sources when making their point. A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be selective

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the review’s focus, whether it is thematic, methodological, or chronological.

Use quotes sparingly

Falk and Mills do not use any direct quotes. That is because the survey nature of the literature review does not allow for in-depth discussion or detailed quotes from the text. Some short quotes here and there are okay, though, if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Notice that Falk and Mills do quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. But if you find yourself wanting to put in more quotes, check with your instructor.

Summarize and synthesize

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. The authors here recapitulate important features of Hamilton’s study, but then synthesize it by rephrasing the study’s significance and relating it to their own work.

Keep your own voice

While the literature review presents others’ ideas, your voice (the writer’s) should remain front and center. Notice that Falk and Mills weave references to other sources into their own text, but they still maintain their own voice by starting and ending the paragraph with their own ideas and their own words. The sources support what Falk and Mills are saying.

Use caution when paraphrasing

When paraphrasing a source that is not your own, be sure to represent the author’s information or opinions accurately and in your own words. In the preceding example, Falk and Mills either directly refer in the text to the author of their source, such as Hamilton, or they provide ample notation in the text when the ideas they are mentioning are not their own, for example, Gastil’s. For more information, please see our handout on plagiarism.

Revise, revise, revise
Draft in hand? Now you’re ready to revise. Spending a lot of time revising is a wise idea, because your main objective is to present the material, not the argument. So check over your review again to make sure it follows the assignment and/or your outline. Then, just as you would for most other academic forms of writing, rewrite or rework the language of your review so that you’ve presented your information in the most concise manner possible. Be sure to use terminology familiar to your audience; get rid of unnecessary jargon or slang. Finally, double check that you’ve documented your sources and formatted the review appropriately for your discipline. For tips on the revising and editing process, see our handout on revising drafts.
Works Consulted

We consulted these works while writing this handout. This is not a comprehensive list of resources on the handout’s topic, and we encourage you to do your own research to find additional publications. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. For guidance on formatting citations, please see the OCOM Library AMA Guide. We revise these tips periodically and welcome feedback.

Anson, Chris M. and Robert A. Schwegler. The Longman Handbook for Writers and Readers. 6th edition. New York: Longman, 2010.

Jones, Robert, Patrick Bizzaro, and Cynthia Selfe. The Harcourt Brace Guide to Writing in the Disciplines. New York: Harcourt Brace, 1997.

Lamb, Sandra E. How to Write It: A Complete Guide to Everything You’ll Ever Write. Berkeley, Calif.: Ten Speed Press, 1998.

Rosen, Leonard J. and Laurence Behrens. The Allyn and Bacon Handbook. 4th edition. Boston: Allyn and Bacon, 2000.

Troyka, Lynn Quitman. Simon and Schuster Handbook for Writers. Upper Saddle River, N.J.: Prentice Hall, 2002.

This literature review section was created by The Writing Center, University of North Carolina at Chapel Hill.

Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License.
DAOM Case Studies
Behall D. Acupuncture and moxibustion for the treatment of two oblique displaced fractures of the left clavicleMeridians. 2018;5(4):23-27. 
Cahill K. A benign complex ovarian cyst treated with Traditional Chinese Medicine: a case study. American Acupuncturist. 2012;58:24-33.  
Cheng I. Thawing the frozen shoulder: A case study and clinical recommendations for the use of acupuncture in treatment of adhesive capsulitis. American Acupuncturist. 2013;62:25-29.
Cooper F. A case of post-surgical knee and thigh pain with numbness treated with acupuncture and associated therapies. American Acupuncturist. 2013;62:16-18. 
Handlin J. A case study on infertility due to endometriosis and advanced maternal age treated with Traditional Chinese Medicine. American Acupuncturist. 2012; 61:26-29. 
Kozik B. The treatment of chronic migraine in a long-term survivor of HIV: A Traditional Chinese Medicine case report. American Acupuncturist. 2013;63:27-31.
Lee C. The treatment of fibromyalgia associated pain using acupuncture: a case study. American Acupuncturist. 2014;66:22-26. 
Parzynski M. Local acupuncture and distal gua sha for the treatment of recurring ankle sprainsMeridians. 2018;5(4):35-39
Payant M. A single case study: treating migraine headache with acupuncture, chinese herbs, and dietGlob Adv Health Med. 2014;3(1):71–74. 
Stanford R. Recurrent miscarriage syndrome treated with acupuncture and an allergy elimination/desensitization technique. Alternative Therapies in Health and Medicine. 2009;15(5):62-63.
Widrin C. Scalp acupuncture for the treatment of motor function In acute spinal cord injury: a case reportJournal of Acupuncture and Meridian Studies .2018;1(2):74-76.
Ye CX. Treatment of macular degeneration with acupuncture: a case reportMeridians. 2015:2(3);12-18.
Articles to Read
Chiu E. Using a Rubric to Evaluate Quality in Case Study Writing. Meridians. Fall 2017:31-40.

Guidelines To writing a clinical case report. Heart Views. 2017;18(3):104-105. doi:10.4103/1995-705X.217857

Vinjamury SP. How to write a case report. American Acupuncturist (reprinted in Meridians). Spring 2012;(55):25.
Isaacs L. Evaluating anecdotes and case reports. Alternative Therapies In Health & Medicine. March 2007;13(2):36-38.
White A. Writing case reports – author guidelines for Acupuncture in Medicine. Acupuncture in Medicine. 2004;22(2):83-86.
Kienle G, Hamre H, Portalupi E, Kiene H. Improving the quality of therapeutic reports of single cases and case series in oncology--criteria and checklist. Alternative Therapies In Health And Medicine. September 2004;10(5):68-72.
Books to Read
Writing Acupuncture Case Reports: Theory and Practice
Ed Chiu
Vancouver, WA: Acupuncture Case Reports, LLC, 2020

How to Do Your Case Study : a Guide for Students and Researchers
Gary Thomas
London: Sage, 2011
Case Study Research and Applications: Design and Methods
Robert Yin
Sage, 2017
The Art of Case Study Research 
Robert E. Stake
Thousand Oaks : Sage Publications, 1995
How to Read a Paper (print and online versions available)
Trisha Greenhalgh
Hoboken : Wiley, 2010
Acupuncture in Practice: Case History Insights from the West 
Hugh McPherson, Ted Katpchuk
New York: Churchill Livingstone, 1997
Citing in AMA
You'll need to cite your sources at the end of your paper in AMA format. AMA Style is used by most journals in our field, so knowing how to use AMA style in your paper will be beneficial if you ever decide to publish a case study in the future. AMA is different from other formats in that it uses superscript numbers within the text of your paper.

Need help with AMA? Check out our style guide at the link below:
Just want a quick computer-generated citation? Try one of these free resources: