How to Write a Case Report
To write an effective case report, follow the SCARE (Surgical CAse REport) guidelines, which provide a comprehensive framework for structuring your report with all essential components to ensure completeness and transparency.1
Essential Components
Title and Keywords
- Include "case report" in the title along with the specific focus area (presentation, diagnosis, 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: Explain what makes the case unique or educational and its importance 1
- Patient's main concerns and important clinical findings 2
- Main diagnoses, therapeutic interventions, and outcomes 2
- 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 3
- Mention the nature of the institution where the patient was managed (academic, community, or private practice) 1
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, family history (including genetic information when relevant), and psychosocial history 1
Clinical Findings
- Present relevant physical examination findings and other significant clinical findings 1
- Include clinical photographs where relevant (with patient 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 specific details on anesthesia, positioning, equipment, and techniques 1
- Document the operator's experience level and any modifications to standard approaches 1
- Include intra-operative photographs/videos when relevant 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 how they were managed 1
- Include future surveillance requirements when applicable 1
Discussion
- Analyze strengths, weaknesses, and limitations in your approach to this case 1
- Compare and contrast with relevant literature 1
- Explain the rationale for your conclusions 1
- Emphasize the primary "take-away" lessons from this case report 1
Additional Required Elements
- Include the patient's perspective on the treatments received when appropriate 1
- State that informed consent was obtained from the patient 1
- Include conflicts of interest, sources of funding, and ethics committee approval when required 1
Common Pitfalls to Avoid
- Presenting information in a non-chronological order, which can confuse readers 3
- Including irrelevant material or excessive detail that obscures the essence of the report 4
- Failing to emphasize the salient features of the case and their relation to previous knowledge 4
- Engaging in unjustified speculation that can nullify the value of the case report 4
- Focusing only on the rarity of a disease without providing a clear "learning point" 5
Key Principles for Success
- Ensure the case warrants publication by advancing understanding of a disorder, increasing clinical skill, or suggesting useful research 4
- Be concise and include only pertinent information 4
- Use illustrations, tables, and graphs to enhance the educational value and reduce data to interpretable form 4
- Verify that your case provides a clear "take-home message" for the reader 5
- Follow the CARE or SCARE guidelines checklist to ensure completeness 6, 1