How do I write a case report?

How to Write a Case Report

Follow the SCARE guideline for surgical cases or the CARE guideline for medical cases, ensuring you include all 13 essential components in a structured, chronological format that emphasizes what makes your case unique and educational. 1, 2, 3

Title and Keywords

• Include the words "case report" in your title along with the specific focus area (presentation, diagnosis, technique, or outcome) 1, 2, 3
• Select 3-6 keywords that identify key areas covered, always including "case report" as one of them 2, 3, 4

Abstract Structure

Your abstract should contain four distinct sections 1:

• Introduction: State what makes this case unique or educational and what it adds to medical literature 1, 2, 3
• Main symptoms and clinical findings: Summarize the patient's presenting complaint and important examination findings 1, 4
• Diagnoses and interventions: Outline the primary diagnoses and therapeutic interventions performed 1, 4
• Conclusion: Highlight the main "take-away" lessons from this case 1, 4

Introduction Section

• Provide 1-2 paragraphs explaining why this case is unique or educational 1, 2, 3
• Reference relevant medical literature and current standards of care to establish context 2, 4
• Explain why the case warrants publication—does it describe an unusual clinical syndrome, association, reaction, treatment, or advance basic understanding? 5

Patient Information

Include comprehensive de-identified demographic details 1, 2, 3:

• Age, sex, ethnicity, occupation 1, 2, 3
• BMI if relevant, hand dominance for surgical cases 2, 3
• Mode of presentation (ambulance, walk-in, referral) 4
• Main concerns and presenting symptoms 1, 4
• Complete medical, surgical, and drug history 1, 3
• Relevant family history including genetic information 1, 4
• Psychosocial history and allergies 4
• Relevant past interventions and their outcomes 1, 3, 4

Clinical Findings

• Present relevant physical examination findings in a systematic manner 1, 2, 4
• Include only pertinent positive and negative findings—avoid irrelevant material or excessive detail that obscures the essence of your report 5

Timeline

• Present the sequence of events in chronological order 3, 4
• Use a table or figure to clarify complex timelines 4
• Document any delays between presentation and intervention 1, 4
• Critical pitfall: Presenting information in non-chronological order confuses readers and weakens your report 3, 4

Diagnostic Assessment

• Detail all diagnostic methods used: physical exam, laboratory testing, imaging, histopathology, and radiological images 1, 2, 3
• Explain your diagnostic reasoning and differential diagnoses considered 1, 4
• Describe any diagnostic challenges (access, financial, cultural) 1
• Include prognostic characteristics when applicable (e.g., tumor staging in oncology) 1, 4

Therapeutic Intervention

For all cases, document 1, 2, 4:

• Pre-intervention considerations and patient optimization measures 2, 4
• Types of intervention (pharmacologic, surgical, preventive, self-care) 1
• Reasoning behind treatment choices 3, 4
• Administration details (dosage, strength, duration) 1
• Changes in intervention with rationale 1

For surgical cases specifically, include 1, 4:

• Anesthesia type and positioning 4
• Surgical technique and materials used 1
• Specific surgical tools or equipment needed 1
• Level of difficulty and anticipated learning curve 1
• Operator's experience level 4
• Any modifications to standard approaches 4
• Concurrent treatments (antibiotics, analgesics, nil-per-os) 1
• Postoperative surgical stay 1

Follow-up and Outcomes

• Report both clinician-assessed and patient-reported outcomes with specific time periods 2, 3, 4
• Document all complications or adverse events in detail, including how they were managed 2, 3, 4
• Include future surveillance requirements when applicable 3, 4

Discussion Section

This is the most important section of your case report 6:

• Evaluate the patient case for accuracy, validity, and uniqueness 6
• Compare and contrast your case with published literature 6
• Emphasize the salient features and show their relation to previous knowledge 5
• Analyze strengths, weaknesses, and limitations in your approach 2
• Derive new knowledge or generalizations when warranted by the evidence 6, 5
• Draw evidence-based recommendations and discuss applicability to practice 6
• Avoid unjustified speculation, which can nullify the value of your report 5

Patient Perspective and Ethics

• Include the patient's perspective on treatments received when appropriate 2, 3, 4
• Explicitly state that informed consent was obtained from the patient 2, 3
• Disclose conflicts of interest, funding sources, and ethics committee approval when required 2

Submission Requirements for Surgical Cases

• Submit a completed SCARE checklist with your manuscript 1, 3
• Explicitly state in your report that you have complied with the SCARE guideline and cite it 1, 3
• The guideline represents the minimum that should be reported—provide additional relevant details as needed 1

Key Principles to Remember

• Conciseness is paramount—include only pertinent information 5
• Use illustrations, tables, and graphs to add visual appeal and enhance educational value, keeping them simple, compact, and self-contained 5
• Include only essential citations that you have carefully reviewed and verified 5
• Ensure your case report is factual, logically organized, clearly presented, and readable 5