What are the steps to write a case report?

How to Write a Case Report: Step by Step Guide

The most effective way to write a case report is to follow the SCARE (Surgical CAse REport) guidelines, which provide a comprehensive, structured approach to ensure your case report is complete, transparent, and valuable to medical literature. 1

Essential Components

Title and Keywords

• Include "case report" in the title along with the specific focus area (presentation, diagnosis, technique, or outcome) 1, 2
• Select 3-6 keywords that identify key areas covered in the case (always include "case report" as one of the keywords) 1, 3

Abstract

• Introduction: Clearly state what makes the case unique or educational and its importance to medical literature 1, 2
• 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, 3

Introduction

• Provide a concise summary (1-2 paragraphs) explaining why the case is unique or educational 1, 2
• Reference relevant medical literature and current standards of care 2
• State the nature of the institution where the patient was managed (academic, community, or private practice) 1

Patient Information

• Include demographic details (de-identified): age, sex, ethnicity, occupation, and other relevant information (BMI, hand dominance if applicable) 1, 3
• 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, 2
• Include medication history, allergies, psychosocial history (including smoking status), and family history with relevant genetic information 1, 3

Clinical Findings

• Present relevant physical examination findings in a systematic manner 1, 2
• Include clinical photographs where relevant and where consent has been given 1

Timeline

• Present the sequence of events in chronological order (use a table or figure for complex timelines) 1, 2
• Document any delays between presentation and intervention 1, 3

Diagnostic Assessment

• Detail all diagnostic methods used: physical exam, laboratory testing, imaging, histopathology 1, 2
• Explain diagnostic reasoning and differential diagnoses considered 1
• Describe diagnostic challenges encountered (access, financial, cultural) 1
• Include prognostic characteristics when applicable (e.g., tumor staging) with relevant radiological or histopathological images 1, 3

Therapeutic Intervention

• Describe pre-intervention considerations and patient optimization measures 1, 2
• Detail the interventions performed (pharmacologic, surgical, etc.) and reasoning behind treatment choices 1, 3
• For surgical cases, include specific details on anesthesia, positioning, equipment, techniques, and medical devices (manufacturer and model) 1
• Document the operator's experience level and any modifications to standard approaches 1, 2

Follow-up and Outcomes

• Report clinician-assessed and patient-reported outcomes with specific time periods 1, 3
• Document complications or adverse events in detail, including how they were prevented, diagnosed, and managed 1, 2
• Include intervention adherence/compliance information 1
• Specify future surveillance requirements when applicable 1, 3

Discussion

• Describe the strengths and limitations of your approach to this case 1
• Compare and contrast the case with published literature 1
• For new techniques or implants, discuss contraindications, alternatives, potential risks, and possible complications 1
• Emphasize the main "take-away" lessons from the case 1

Additional Required Elements

• Include the patient's perspective on the treatments received when appropriate 1, 3
• State that informed consent was obtained from the patient 1, 3
• Submit a completed SCARE checklist with the manuscript if reporting a surgical case 1, 3

Common Pitfalls to Avoid

• Including irrelevant material or excessive detail that obscures the essence of the report 4
• Presenting information in a non-chronological order, which can confuse readers 3
• Focusing only on the rarity of a disease rather than providing a clear "learning point" 5
• Including unjustified speculation that can nullify the value of the case report 4
• Failing to provide appropriate documentation and essential citations 4

Final Tips

• Ensure your case report is factual, concise, logically organized, clearly presented, and readable 4
• Make sure the case warrants publication by advancing understanding of a disorder, increasing clinical skill, or suggesting useful research 4
• Include only pertinent positive and negative findings 5
• Use illustrations, tables, and graphs to enhance the educational value of the report 4
• Begin with a clear title and end with an informative summary 4, 6