What is the template for writing a case presentation?

Template for Writing a Medical Case Presentation

Follow the SCARE (Surgical CAse REport) guideline structure, which provides a comprehensive, consensus-based framework for organizing case presentations that ensures all critical elements are systematically addressed. 1

Title and Keywords

• Include "case report" in the title along with the specific focus area (presentation, diagnosis, surgical technique, or outcome) 2, 3, 4
• Select 3-6 keywords identifying key areas covered, always including "case report" as one keyword 2, 3, 4

Abstract

Structure the abstract to include four essential components 2:

• Introduction: State what makes the case unique or educational and its importance to medical literature 2, 3
• Presenting complaint: Summarize the patient's main concerns and important clinical findings 2
• Main diagnoses and interventions: Outline primary diagnoses and therapeutic interventions performed 2
• Conclusion: Highlight the main "take-away" lessons from the case 1, 2

Introduction (1-2 paragraphs)

• Provide a concise summary explaining why the case is unique or educational 1, 2, 3, 4
• Reference relevant medical literature and current standards of care 1, 2, 4
• Describe the nature of the institution (academic, community, or private practice setting) 1

Patient Information

Demographic and baseline data 1, 2, 4:

• De-identified demographic details: age, sex, ethnicity, occupation 1, 2, 3, 4
• Other pertinent information: BMI, hand dominance if applicable 1, 2, 4

Presentation details 1, 2:

• Presenting complaint and symptoms 1
• Mode of presentation (ambulance, walk-in to emergency room, referral by family physician) 1, 2

Medical history 1, 2, 4:

• Past medical and surgical history with relevant outcomes from previous interventions 1, 2, 4
• Medication history and allergies 2
• Family history, including relevant genetic information 1, 2
• Psychosocial history: smoking status, accommodation type, walking aids, etc. 1, 2

Clinical Findings

• Present relevant physical examination findings in a systematic manner 1, 2, 3
• Include other significant clinical findings 1, 3
• Add clinical photographs where relevant and where consent has been given 1

Timeline

• Present the sequence of events in chronological order 2, 4
• Use a table or figure to clarify complex timelines 2, 4
• Document any delays between presentation and intervention 1, 2

Common pitfall: Avoid presenting information in non-chronological order, which confuses readers 2, 4

Diagnostic Assessment

Diagnostic methods 1, 2, 3, 4:

• Detail all diagnostic methods used: physical exam, laboratory testing, radiological imaging, histopathology 1, 2, 3, 4

Diagnostic reasoning 1, 2:

• Explain diagnostic reasoning and differential diagnoses considered 1, 2
• Describe diagnostic challenges (access, financial, cultural) 1

Prognostic information 1, 2:

• Include prognostic characteristics when applicable (e.g., tumor staging) 1, 2
• Add relevant radiological or histopathological images 1

Therapeutic Intervention

Pre-intervention considerations 1, 2, 3, 4:

• Describe patient optimization measures taken prior to surgery or other intervention (e.g., treating hypothermia/hypovolemia/hypotension, ICU care for sepsis, managing anticoagulation/medications) 1, 2, 3

Intervention details 1, 2, 4:

• Specify types of interventions deployed (pharmacological, surgical, physiotherapy, psychological, preventive) and reasoning behind treatment choices 1, 2, 4
• List concurrent treatments (antibiotics, analgesia, anti-emetics, nil by mouth, VTE prophylaxis) 1
• For medical devices, mention manufacturer and model specifically 1

Peri-intervention details 1, 2:

• For surgical cases: anesthesia type, patient position, tourniquet use, prep used, sutures, devices, surgical staging (1 or 2 stage) 1, 2
• For pharmacological therapies: formulation, dosage, strength, route, duration 1

Operator information 1:

• Document operator experience, position on learning curve for the technique, specialization, and prior relevant training 1
• Note degree of novelty for surgical technique/device (e.g., "first in-human") 1

Modifications 1:

• Document any changes in interventions with rationale 1
• Include intra-operative photographs and/or video or relevant histopathology 1

Post-intervention 1:

• Describe post-operative instructions and place of care 1

Follow-up and Outcomes

Outcome measures 1, 2, 3, 4:

• Report clinician-assessed and patient-reported outcomes with specific time periods at which assessed 1, 2, 3, 4
• Provide relevant photographs/radiological images (e.g., 12-month follow-up) 1

Complications 3, 4:

• Document complications or adverse events in detail, including how they were managed 3, 4

Follow-up testing and surveillance 1, 4:

• Report important follow-up diagnostic and other test results 1
• Include future surveillance requirements when applicable (e.g., imaging surveillance of EVAR, clinical exam/ultrasound of regional lymph nodes for skin cancer) 1, 4

Discussion

Case analysis 3:

• Analyze strengths, weaknesses, and limitations in your approach to this case 3

Patient perspective 3, 4:

• Include the patient's perspective on the treatments received when appropriate 3, 4

Administrative Requirements

Consent and ethics 3, 4:

• State that informed consent was obtained from the patient 3, 4
• Include conflicts of interest, sources of funding, and ethics committee approval when required 3

Guideline compliance 4:

• Submit a completed SCARE checklist with the manuscript if reporting a surgical case 4
• Explicitly state compliance with the SCARE guideline in the report 4