A case report is a narrative that describes, for medical, scientific, or educational purposes, a medical problem experienced by one or more patients.1 Translating a case report sounds straightforward. But is it? This blog post stems from a recent project in which I reviewed several case reports translated from Spanish to English.
Experience … and other resources
My experience is long, but limited by its subjective nature. I’ve therefore tried to approach this topic from a more objective perspective, basing my recommendations on:
- The CARE (CAse REport) Guidelines1
- An article by Beatriz Méndez-Cendón entitled, “Combinatorial patterns in medical case reports: an English-Spanish contrastive analysis.”2
- The AMA Manual of Style3
- My own ‘quick and dirty’ corpus of native English case reports. I compiled this corpus from about 80 case reports (200,000 words) and compared my findings with a much smaller corpus built from just 20 English language case reports written by authors or translators in Spain, Italy and Portugal.4
Instructions for Authors
Ask your client where the case report is to be published. Journals usually have Instructions for Authors that you should read and follow. Some even have a case report template,5,6 so you may need to adapt the source text if the author hasn’t followed it.
Pharmaceutical companies write case reports to show how safe and effective their products are. In this case, there may not be any specific instructions or templates at all.
Structure
In general, a case report consists of an abstract, introduction, case presentation and discussion.
Abstract
This summarises the main points of the article. It may be written as a single continuous paragraph or structured under headings. Avoid abbreviations.
Introduction / Background
This must attract the reader’s attention. It must be concise and salient. The first person plural is often used to introduce the case, both in English and Spanish4:
We present a new case of…
Presentamos un nuevo caso de…
Case Presentation / Case Description
This is the core of a case report. It starts by describing the presenting signs and symptoms, moves on to the physical examination and investigations, and ends with the diagnosis, treatment and outcome.
Presenting signs and symptoms
Use the past tense and full sentences in a narrative format.
A 54-year-old man was admitted to …
A 66-year-old woman presented to our hospital …
Note that the verb present can take different prepositions. A patient presents to/at a hospital/outpatients’ clinic, but presents with initial signs or symptoms. However, when more signs and symptoms are mentioned, just use had or developed.
Don’t get misled by the Spanish use of presentar, which is far more common than in English.
Spanish case reports invariably use the present tense and a short, succinct style, even omitting indefinite articles. Mujer de 66 años de edad que acude a consulta.
A literal translation (66-year-old woman attends clinic) illustrates the contrasting Spanish/English styles. In English, think full and flowing.
Man/woman is used much more frequently than male/female as a standalone noun.4 In my non-native English corpus, use of man/woman and male/female was almost equal.
A 72-year-old male presented with jaundice.
Returning to my native English corpus, baby boy/girl is much more common than male/female baby.
Physical examination and investigations
In the sub-section that describes the physical examination and investigations, English case reports use the active voice and verbs such as revealed and showed.2 Interestingly, the first person plural (we) does not tend to be used to describe findings.4
There are two common ways to start this part2:
Physical examination revealed tenderness… (note the absent definite article)
On physical examination, the patient was hypotensive…
Spanish syntax differs here. It uses the reflexive passive voice and the present tense: En la exploración física se percibe un fuerte aumento…
Make the time sequence clear, using the past perfect if an event precedes the current illness1: He had had diarrhoea and fever for two weeks …
Diagnosis
The last part of the case presentation may include any or all of the following: Diagnosis, Treatment, Management, Outcome and Follow Up. The focus and length of this sub-section depends on the purpose of the case report.7
Don’t abuse of as a genitive. English translations of Spanish texts can be spotted a mile off if the translator doesn’t turn the phrase around:
An injury of the cornea (corneal injury)
Inhibitor of vascular endothelial growth (vascular endothelial growth inhibitor)
Discussion
This section switches to the present tense. It describes similar cases and discusses the novelty of the reported case. It can also be used to explain treatment decisions.
Don’t confuse the words case and patient. Case refers to a particular instance of a disease, whereas a patient is a person who receives medical care.3
This case developed symptoms of… is incorrect.
Other sections
Other sections may be added after the discussion, such as a conclusion or simple take-home messages in bullet points. The patient’s perspective may also be included in the form of a verbatim account. Make sure you use the same register, without technical terms or medical jargon.
The patient’s informed consent is important in a case report, because certain details (photos, occupation, race, city) may make the patient feel that he or she can be identified.
As with other articles, case reports end with acknowledgements and references.
Make sure you translate the Spanish heading bibliografía as references, not bibliography.
Check list
Here’s a check list summary of this rather random collection of tips for translating case reports:
| × | Journal template – use if there is one |
| × | Present tense for the introduction and discussion |
| × | Full sentences, not telegraphic style |
| × | Past tense for the case presentation section |
| × | “We” in the introduction and discussion |
| × | case ≠ patient |
| × | bibliografía ≠ bibliography |
References
Signs & Symptoms of Translation 
Hi Emma, speaking as a colleague who also works on case reports for clients, this post was directly relevant to me. I was especially interested to read of journal templates and I will look for these next time a case report lands on my desk. I recently helped a paediatric surgeon publish a case report and we discovered that her target journal actually had a sub-journal aimed solely at publishing case reports. However, she was gunning after another title with a higher impact factor and rejected this option. I also agree entirely with your take on tenses for different sections which is broadly speaking along the same lines as what I apply in my own work. Many thanks for this very interesting post!
Thanks for your comment, Jason. It’s great to have the chance to work directly with the author for these projects. I often have an agency as an intermediary, which can add an extra obstacle to the process.
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Hello, I work for a medical writing company and often get medical documents to translate from various foreign language into English. A proper template is definitely important but a medical writer should also ensure that none of the sensitive information is lost in translation. One of the biggest factors is cultural diversity; a person belonging to one culture might perceive a meaning differently than a person belonging to another culture and that can create misunderstanding. However, you have given me very good pointers for translating in this post. Thanks.