How do I write a medical case report?

How to Write a Medical Case Report

To write an effective medical case report, follow the SCARE (Surgical CAse REport) guidelines, which provide a comprehensive structure for reporting unique or educational clinical cases. 1

Essential Components

Title and Keywords

• Include "case report" in the title along with the specific focus area (presentation, diagnosis, surgical technique, or outcome) 1
• Select 3-6 keywords that identify key areas covered in the case (always include "case report" as one of the keywords) 1

Abstract

• Introduction: Clearly state what makes the case unique or educational and its importance to medical literature 1
• Presenting complaint: Summarize the patient's main concerns and important clinical findings 1
• Main diagnoses and interventions: Outline the primary diagnoses and therapeutic interventions performed 1
• Conclusion: Highlight the main "take-away" lessons from the case 1

Introduction

• Provide a concise summary (1-2 paragraphs) explaining why the case is unique or educational 1
• Reference relevant medical literature and current standards of care 1
• Establish the purpose and merit of reporting this particular case 2

Patient Information

• Include de-identified demographic details (age, sex, ethnicity, occupation, BMI if relevant) 1
• Describe the presenting complaint and mode of presentation (ambulance, walk-in, referral) 1
• Document relevant past medical/surgical history and outcomes from previous interventions 1
• Include medication history, allergies, psychosocial history (smoking, drug use), and family history 1

Clinical Findings

• Present relevant physical examination findings systematically 1
• Include clinical photographs where relevant and with appropriate consent 1

Timeline

• Present the sequence of events in chronological order (table or figure may help) 1
• Document any delays between presentation and intervention 1

Diagnostic Assessment

• Detail all diagnostic methods used (physical exam, laboratory testing, imaging, histopathology) 1
• Explain diagnostic reasoning and differential diagnoses considered 1
• Include prognostic characteristics when applicable (e.g., tumor staging) 1
• Add relevant radiological or histopathological images 1

Therapeutic Intervention

• Describe pre-intervention considerations and patient optimization measures 1
• Detail the interventions performed (pharmacologic, surgical, etc.) and reasoning behind treatment choices 1
• For surgical cases, include specifics on anesthesia, positioning, equipment, and techniques 1
• Document concurrent treatments (antibiotics, analgesia, VTE prophylaxis, etc.) 1
• Specify medical devices with manufacturer and model information 1

Follow-up and Outcomes

• Report clinician-assessed and patient-reported outcomes with specific time periods 1
• Document complications or adverse events in detail, including management 1
• Include future surveillance requirements when applicable 1

Discussion

• Evaluate the case for accuracy, validity, and uniqueness 2
• Compare and contrast with published literature 1
• Explain the rationale for conclusions 1
• Summarize the essential features and "take-away" lessons 1, 3

Patient Perspective

• When appropriate, include the patient's perspective on the treatments received 1

Informed Consent

• State whether informed consent was obtained from the patient 1

Writing Tips for Effective Case Reports

Focus on Relevance and Conciseness

• Ensure the case warrants publication by providing new insights or educational value 3
• Include only pertinent positive and negative findings, avoiding irrelevant details 3
• Be concise and logically organized throughout the report 3, 4

Quality Considerations

• Select cases that provide clear "learning points" rather than focusing solely on rarity 4
• Ensure factual accuracy and avoid unjustified speculation 3
• Use illustrations, tables, and graphs to enhance educational value and readability 3

Common Pitfalls to Avoid

• Presenting information in a non-chronological order, which can confuse readers 5
• Including excessive detail that obscures the essence of the report 3
• Withholding relevant information or engaging in unwarranted speculation 3
• Failing to provide adequate literature review to contextualize the case 2

Submission Considerations

• Follow the specific guidelines of the target journal 4
• Submit a completed SCARE checklist with your manuscript if reporting a surgical case 1
• Explicitly state compliance with the SCARE guideline in your report 1