WRITING A CASE REPORT Important Considerations. (1) Patient information must be de-identified (2) Necessary approvals and consents should have been obtained, and (3) Potential competing interests should be disclosed. Title. The words case report should be in the title. Key elements of the case should be mentioned in the title and might include the presenting symptoms, the diagnosis, intervention, or outcome. Abstract. In about 200 words summarize the: (1) Rationale for this case report, (2) Presenting concerns of the patient, (3) Diagnoses, (4) Interventions (including prevention and lifestyle), (5) Outcomes, and (6) Main lessons learned from this case. Key Words. Provide 2 to 5 key words that will assist in an online search for this case report. Introduction. Briefly summarize the background and context of this case report. Presenting Concerns. Summarize the patients presenting concerns along with key historical data and demographic information. Clinical Findings. Summarize the (1) Medical, family, and psychosocial history (including lifestyle and genetic information); (2) Pertinent co-morbidities and interventions; and (3) Physical examination focused on the important findings including diagnostic testing. Timeline. Create a timeline that includes specific dates and times in a table, figure, or graphic. Diagnostic Focus and Assessment. Summarize the (1) Diagnostic results (testing, imaging, questionnaires, referrals); (2) Diagnostic challenges; (3) Diagnostic reasoning and (4) Relevant prognostic characteristics (such as staging). Therapeutic Focus and Assessment. Summarize recomendations and interventions (pharmacologic, surgical, lifestyle) and how they were administered (dosage, strength, etc.) Follow-up and Outcomes. Summarize the clinical course of this case. How was patient adherence to the intervention assessed and and were adverse events noted? Summarize patient-reported outcomes and follow-up diagnostic testing. Discussion. Summarize the strengths and limitations associated with this case report. Include references to the scientific and medical literature. How did you arrive at your conclusions and how might these results apply to other patients? What are the take-away messages? Patient Perspective. When appropriate, the patient should share their experience of their care in a brief narrative published with (or accompanying) this case report. Informed Consent. The patient should provide informed consent for this case report.
Posted on: Sun, 07 Dec 2014 13:43:37 +0000
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