How to Prepare a Case Report: A Structured Approach
Follow the SCARE (Surgical CAse REport) 2018 guidelines as your primary framework for preparing a surgical case report, which provides a comprehensive, consensus-based checklist that ensures high-quality reporting. 11
Essential Structure and Components
Title and Keywords
- Include the words "case report" explicitly in your title
- Describe the specific focus area (presentation, diagnosis, surgical technique, device, or outcome)
- Select 3-6 keywords covering the case's main topics, including "case report" as one keyword 11
Abstract (Four Required Components)
Your abstract must contain:
- Introduction: State what makes this case unique or educational and why it matters to the surgical literature
- Presenting complaint and investigations: Summarize the patient's main concerns and key clinical findings
- Main diagnoses, interventions, and outcomes: Provide the essential clinical information
- Conclusion: Articulate the main "take-away" lessons from this case 11
Introduction Section
Write 1-2 referenced paragraphs that:
- Summarize what is unique or educational about your case
- Reference relevant surgical literature
- Describe the current standard of care 11
Patient Information (Critical Details)
Demographic information (de-identified):
- Age, sex, ethnicity, occupation
- Body mass index, hand dominance (when relevant)
Presentation details:
- Presenting symptoms
- Mode of arrival (ambulance, walk-in, physician referral)
Complete histories:
- Past medical and surgical history with intervention outcomes
- Pharmacological history including allergies
- Psychosocial history (drugs, smoking, accommodation, walking aids)
- Family history with relevant genetic information 11
Clinical Findings
Document relevant physical examination findings and significant clinical observations. Include clinical photographs where appropriate and when consent has been obtained 11
Timeline
Create a table or figure showing the sequence of events in the patient's history and presentation. Specifically report the delay from presentation to intervention 11
Diagnostic Assessment (Four Components)
- Diagnostic methods: Physical exam, laboratory testing, radiological imaging, histopathology
- Diagnostic challenges: Access issues, financial barriers, cultural considerations
- Diagnostic reasoning: Differential diagnoses and rationale for considering them
- Prognostic characteristics: Tumor staging, genetic condition staging, with relevant radiological or histopathological images 11
Therapeutic Intervention Details
Pre-intervention considerations:
- Patient-specific optimization measures (treating hypothermia, hypovolemia, hypotension, ICU treatment for sepsis, managing anticoagulation)
Interventions:
- Type of intervention (pharmacologic, surgical, physiotherapy, psychological, preventive)
- Reasoning behind the treatment choice
- Concurrent treatments (antibiotics, analgesia, anti-emetics, nil by mouth, venous thromboembolism prophylaxis) 11
Key Principles for Success
Case selection matters: Don't focus solely on rarity. Your case must provide a clear "learning point" that offers useful insights or highlights clinical pitfalls 2. The case should be unusual, unexpected, or demonstrate important educational value 34.
Writing style: Keep it clear, concise, coherent, with a crisp take-home message 2. Case reports should chronologically chronicle events in an ethical, educational manner that reviewers can appraise 3.
Common Pitfalls to Avoid
- Failing to obtain proper patient consent before writing
- Selecting cases based only on rarity without educational value
- Omitting the delay from presentation to intervention in the timeline
- Not including differential diagnoses and diagnostic reasoning
- Forgetting to de-identify patient information adequately
- Neglecting to reference the introduction section properly
The SCARE checklist provides a simple yet comprehensive framework that enhances transparency, clinical interpretability, and relevance 11. This structured approach helps generate scholarly output, particularly valuable for new medical writers 5, and can serve as a catalyst for scientific discovery while contributing to clinical diagnosis and management 4.