Can you help create a case report?

How to Write a Medical Case Report

Yes, I can help you create a case report—follow the SCARE (Surgical CAse REport) guidelines if it's a surgical case, or the CARE (CAse REport) guidelines for medical cases, which provide a structured framework to ensure your report is complete, transparent, and publication-ready. 1

Essential Structure and Components

Title and Keywords

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

Abstract (Structured in 4 Parts)

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

Introduction Section

• Provide 1-2 paragraphs explaining why this case is unique or educational, with references to relevant medical literature and current standards of care. 1, 2
• Specify the nature of the institution (academic, community, or private practice setting). 1

Patient Information (De-identified)

• Demographics: Include age, sex, ethnicity, occupation, BMI (if relevant), and hand dominance (if relevant). 1, 2
• Presenting complaint: Describe the main symptoms and mode of presentation (e.g., ambulance, walk-in, physician referral). 1, 3
• Past medical/surgical history: Document relevant outcomes from previous interventions. 1, 2, 4
• Medication history, allergies, family history (including genetic information when relevant), and psychosocial history (smoking status, accommodation type, walking aids). 1, 3

Clinical Findings

• Present relevant physical examination findings in a systematic manner, including clinical photographs where appropriate and consent has been obtained. 1, 3

Timeline

• Present the sequence of events in chronological order—use a table or figure to clarify complex timelines. 1, 2, 3
• Document any delays between presentation and intervention. 1, 3

Diagnostic Assessment

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

Therapeutic Intervention

• Describe pre-intervention considerations and patient optimization measures. 1, 3
• Detail the type of intervention (pharmacologic, surgical, preventive, self-care) and the reasoning behind treatment choices. 1, 2, 3
• For surgical cases, include: anesthesia type, patient positioning, specific surgical tools/equipment, surgical technique and materials used, level of difficulty, anticipated learning curve, anticipated complications, backup teams, blood loss, and operative time. 1
• Document the operator's experience level and any modifications to standard approaches. 1, 3
• Describe concurrent treatments (antibiotics, analgesics, nil-per-os status). 1

Follow-up and Outcomes

• Report clinician-assessed and patient-reported outcomes with specific time periods (e.g., 12-month follow-up with photographs/radiological images). 1, 3
• Document intervention adherence/compliance—how well the patient adhered to and tolerated treatment (e.g., post-operative restrictions, chemotherapy tolerance). 1
• Describe all complications and adverse events in detail, ideally categorized using the Clavien-Dindo Classification, including how they were prevented, diagnosed, and managed. 1, 3
• If there were no complications, explicitly state this. 1
• Include future surveillance requirements when applicable (e.g., imaging surveillance, clinical exams). 1, 3

Discussion Section

• Strengths: Describe the strengths of your approach to this case. 1
• Weaknesses and limitations: For new techniques or implants, discuss contraindications, alternatives, potential risks, and possible complications if applied to a larger population. 1
• Literature review: Discuss relevant literature, implications for clinical practice guidelines, and any hypothesis generation. 1
• Rationale for conclusions: Explain your reasoning. 1
• Primary take-away lessons: Clearly state the main educational points. 1

Patient Perspective

• Include the patient's perspective on the treatments they received when appropriate. 1, 4

Informed Consent

• State that informed consent was obtained from the patient for publication. 1, 4
• If not obtained (e.g., patient deceased), explain why and document efforts to trace next of kin or identify the hospital guarantor. 1

Additional Information

• Declare conflicts of interest, sources of funding, and institutional review board/ethics committee approval where required. 1, 4

Submission Requirements for Surgical Cases

• Submit a completed SCARE checklist with your manuscript. 1, 2
• Explicitly state in your report that you have complied with the SCARE guideline and cite it. 1, 2

Critical Pitfalls to Avoid

• Do not present information in non-chronological order—this confuses readers and obscures the clinical narrative. 2, 3
• Include only pertinent information—irrelevant details or excessive material can obscure the essence of your report and repel editors. 5
• Be concise—case reports should be short and focused with a limited number of figures and references. 5, 6
• Ensure the case warrants publication—it must describe something truly unusual, advance understanding, increase clinical skill, or suggest useful research. 5, 7

What Makes a Case Report Worthy of Publication

Your case should demonstrate at least one of the following: 5, 6

• A previously unreported clinical condition
• A previously unreported observation of a recognized disease
• Unique use of imaging or diagnostic testing
• Previously unreported treatment approach
• Previously unreported complication of a procedure

Once you provide me with the specific details of your case, I can help you structure it according to these guidelines to maximize its educational value and publication potential.