What is the standard format for a case presentation?

Standard Format for a Medical Case Presentation

A professional medical case presentation follows a structured 13-component format that ensures comprehensive, chronological documentation of the patient encounter, beginning with title/keywords and ending with informed consent documentation. 1, 2

Title and Keywords

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

Abstract Structure

• Write a concise summary (1-2 paragraphs) explaining what makes the case unique or educationally valuable 1, 2
• Summarize the patient's main concerns and important clinical findings 1
• Outline the primary diagnoses and therapeutic interventions performed 1
• Highlight the main "take-away" lessons from the case 1

Introduction

• Provide 1-2 paragraphs explaining why the case is unique or educational, referencing relevant medical literature and current standards of care 1
• Establish the case's importance to medical literature and clinical practice 1

Patient Information (De-identified Demographics)

• Document age, sex, ethnicity, occupation, BMI, and hand dominance when applicable 1, 2, 3
• Describe the presenting complaint and mode of presentation (ambulance, walk-in, referral) 1, 3
• Include relevant past medical/surgical history with outcomes from previous interventions 1, 2, 3
• Document medication history, allergies, psychosocial history, and family history including genetic information when relevant 1, 3

Clinical Findings

• Present relevant physical examination findings in a systematic manner, including only pertinent positive and negative findings 1, 4
• Include clinical photographs where appropriate with documented consent 3

Timeline

Present the sequence of events in strict chronological order—this is critical as non-chronological presentation confuses listeners and readers. 1, 2

• Use a table or figure to clarify complex timelines 1, 2
• Document any delays between presentation and intervention 1

Diagnostic Assessment

• Detail all diagnostic methods used: physical exam, laboratory testing, imaging, and histopathology 1, 2, 3
• Explain diagnostic reasoning and differential diagnoses considered 1, 3
• Include prognostic characteristics when applicable (tumor staging, genetic conditions) 1, 3
• Address diagnostic challenges such as access limitations, financial constraints, or cultural barriers 3

Therapeutic Intervention

• Describe pre-intervention considerations and patient optimization measures 1, 3
• Detail the interventions performed (pharmacologic, surgical, etc.) with clear rationale for treatment choices 1, 2, 3
• For surgical cases, specify anesthesia type, positioning, equipment, techniques, tourniquet use, surgical prep, sutures, and devices with manufacturer/model 1, 3
• Document the operator's experience level, position on learning curve, and any modifications to standard approaches 1, 3
• Include concurrent treatments: antibiotics, analgesia, anti-emetics, nil by mouth status, and venous thromboembolism prophylaxis 3

Follow-up and Outcomes

• Report both clinician-assessed and patient-reported outcomes with specific time periods 1, 2
• Document complications or adverse events in detail, including how they were managed 1, 2
• Specify the setting of care, care provider, and postoperative instructions 3
• Outline follow-up schedule: when, where, and how (imaging, tests, clinical examination, phone calls) 3
• Include future surveillance requirements when applicable 1, 2, 3

Discussion

This is the most important section—it must evaluate the case for accuracy, validity, and uniqueness while comparing it to published literature. 5

• Show how salient features relate to previous knowledge and interpret their significance 4, 5
• Derive new knowledge and draw evidence-based conclusions or generalizations 4, 5
• Suggest further possible studies when warranted 4
• Avoid unjustified speculation that can nullify the report's value 4

Patient Perspective

• Include the patient's perspective on treatments received when appropriate 2

Informed Consent

• State explicitly that informed consent was obtained from the patient 2
• For surgical cases, document that risks, benefits, expected outcomes, and surgical experience were discussed 3

Additional Requirements for Surgical Cases

• Submit a completed SCARE checklist with the manuscript 2
• Explicitly state compliance with the SCARE guideline 2

Key Principles to Ensure Quality

• Be concise—include only pertinent information and avoid irrelevant material or excessive detail that obscures the essence of the report 4, 6
• Use illustrations, tables, and graphs to add visual appeal and reduce statistical data to readily interpretable form 4
• Keep the report factual, logically organized, clearly presented, and readable 4
• Include only essential citations that have been carefully reviewed and verified 4