Stylistic features of case reports as a genre of medical discourse

MCRs are traditionally structured in abstract, introduction, case presentation, discussion, conclusion, informed consent and references. As a rule, the length of a MCR largely depends on the communicative purpose. However, brevity and conciseness are usually the most distinctive features of MCRs as a genre. In general, the author’s aim is to transfer the maximum amount of important information using the minimal linguistic tools. Another unique characteristic of MCRs as compared with other genres of medical discourse is their narrative style. That is to say, the major objective of MCRs is to “narrate”, that is, to describe, an interesting case to fellow researchers in order to warn them or to improve treatment techniques. Consequently, MCRs perform instructive and educational functions, and therefore are aimed at: (1) describing a condition for the first time, and/or (2) warning other physicians. These stylistic features determine the entire structure of MCRs, as well as the choice of lexical units.

It is necessary to admit that the use of simple past tense is a predominant feature of MCRs. This peculiarity results from the very nature of MCRs as narrative (that is, “storytelling”) texts: their primary aim is to give an account of past events. Another important aspect of MCRs is the use of active sentences, contrary to other medical scientific genres, such as research articles. In terms of academic writing, the passive voice and impersonal “it” constructions “depersonalize text and create an impression of the writer’s distance and objectivity” [4], thus providing the necessary effect of academic detachment. However, this is not the case with MCRs. Obviously, this peculiarity is also associated with the narrative style, as well as with the educational intention of MCRs as a genre: the authors of MCRs describe the unusual problem they have faced and handled, thus sharing their experience and a lesson they have learned from it.

Hence, MCRs are notable for their use of active sentences in the simple past tense (309 cases) [3, 5‐18]: “We maintained anesthesia with inhaled desflurane at 5% and intravenously administered remifentanil at 0.2 μg/kg/min in a fraction of inspired oxygen of 0.45 (…) At that moment, we administered 20 mg ephedrine, 300 μg phenylephrine, and 0.03 μg/kg/min norepinephrine to maintain adequate blood pressure (…) We did not detect any problems with his respiratory parameters (…) His systolic blood pressure remained at 40 mmHg for 10 min; we performed chest compressions to maintain his blood pressure” [5]; “We did not find cases with such an evolution in the literature, but we found some cases of spontaneous expulsion of ileal lipoma per rectum” [6]; “We found electrogram amplitude to be normal throughout the right ventricle (…) In this case we used cryoablation to avoid the pain associated with radiofrequency delivery” [7]; “An extraoral examination revealed a diffuse swelling of her left nasal alar base without tenderness” [8]; “Two patients with EHPVO presented with micrognathia, restricted mouth openings, and facial asymmetry” [9]; “Brain magnetic resonance imaging (MRI) did not identify any abnormalities, but an ophthalmic examination revealed vertical supranuclear gaze palsy (VSGP), and analysis of peripheral blood and bone marrow biopsies identified vacuolated histiocytes” [10]; “…we considered electroconvulsive therapy; clinicians may opt for electroconvulsive therapy at an earlier stage in similar psychiatric emergencies (…) We hypothesized that our patient’s poor clinical response was from a genetic polymorphism in the drug-metabolizing activity of cytochrome P450 enzymes” [11].

However, it is necessary to point out that passive voice constructions can also be met in MCRs. In particular, they are used for the purpose of giving recommendations and warning other physicians (that is, implementation of the instructive function). In this context, the modal verb “should” plays a significant role as well (15 cases in the analyzed MCRs): “The psychological aspect of this condition should not be underestimated because he was ashamed of his front teeth and was not able to smile” [12]; “IMA malposition is a rare but potentially lethal complication of CVC that should be considered in risk factor assessments and the management of severe complications resulting from CVC” [13]; “…however, the risk of infection should be weighed against the advantages of this procedure” [8]; “We hypothesize that a difficult intubation should be anticipated in these patients” [9].

The present perfect tense is generally used to render the author’s reflections on the problem in a broader context (for instance, the results of other research, which occur primarily in the “Background” section of MCRs). The research has identified 180 cases of present perfect constructions (103 active and 77 passive sentences): “There have been a number of previous reports of CVC malpositioning in the internal mammary vein”; “Numerous complications of central venous catheterization have been reported” [13]; “Other studies have demonstrated the ability of ablation to prevent recurrence of VF in patients with a structurally normal heart, but these studies also have been of small patient cohorts followed only for a few years” [7]; “Few cases of bilateral nasoalveolar cysts have been described” [8].

In addition, the past perfect tense is applied to describe earlier events from the case history (a total of 34 past perfect constructions: 28 active and 6 passive sentences): “Of note, he had undergone a THA 31 days prior to his transfer…” [14]; “Four months later, his proteinuria had reduced to 1.4 grams/day, creatinine had improved to 155 μmol/L” [15]; “A computed tomography (CT) of her abdomen had shown nonspecific findings suggestive of colitis” [16]; “Two weeks previously, she had given birth at 40 weeks … there had been no antenatal symptoms … our patient had complained of dysuria … the baby had not required hospitalization” [17].

At the same time, our research has demonstrated the relatively seldom use of the future tense in MCRs (a total of 16 cases: 13 active and 3 passive sentences). Occasionally, the authors use it in the “Conclusions” section to provide a perspective for further research or a prognosis: “An ultrasound-guided approach rather than the use of a landmark technique to insert CVC will help” [13]; “Patients will tolerate the procedure with adequate airway preparation using topical anesthesia” [9]; “Until the effectiveness of ablation for the prevention of VF has been confirmed in a large cohort of such patients followed for a substantial duration, we will continue to recommend ICD therapy for most survivors of VF arrest even if ablation is also performed” [7]; “The tooth will preserve the remaining alveolar ridge and help the adolescent psychologically” [12].

The use of the present simple tense is also comparatively infrequent and it is generally used only in the opening section of MCRs (23 cases in the analyzed discourse): “We report a rare case of a CVC tip malpositioned in the right internal mammary artery (IMA)” [13]; “We describe the case of a 30-year-old man from the north of Morocco with no medical or surgical history and no family history of rectal disease” [6]; “We describe a case in which RVOT ectopy was complicated by ventricular fibrillation (VF) arrest despite the absence of any of the recognized risk factor for cardiac arrest and despite an apparently positive response to pharmacological therapy” [7]; “Here, we present two cases where difficult intubation was anticipated, and in which, despite trying various devices to visualize and secure the airway, only the use of a Macintosh blade proved successful” [9]; “We report a case of an acute psychotic relapse in response to polydrug use most notable for multiple recent binges of crystal methamphetamine” [11].

As one can observe from the examples above, the direct manner and personal style of MCRs are vividly embodied in the wide use of the first person plural personal pronoun. The present research has detected 77 cases of using the pronoun “we” in the analyzed MCRs. As a matter of fact, the use of “we” emphasizes the fact of joint authorship: “sole authorship should rarely be undertaken, instead the support and critical appraisal of a number of colleagues, as well as clinical mentors, offers the most likely team to ensure a strong contribution to literature” [19]. Furthermore, the patients are usually referred to as third person pronouns. This narrative strategy is aimed primarily at the protection of patients’ personal information. Hence, all relevant data (for example, a patient’s sex and age) are provided in the first sentence of MCRs, with subsequent referencing as “he” or “she”, so that the patients could not be identified. The research has found 153 cases of referring to patients as “he” or “she” in the analyzed discourse. The following examples demonstrate this strategy:

Thus, while personal pronouns are for the most part avoided in other scientific genres, they constitute a predominant feature of MCRs.