The elements which should be included in writing a case report are as follows:
Title: The guidelines now recommend the words “Case Report” be in the title. This is actually counter to recommendations I have made in the past, where it was felt that since a paper would likely be put in a section of the journal devoted to case reports it was no longer necessary to list it as part of the title. This is a change, but it clarifies what the paper is about.Abstract: Typically, this uses a structured format, but some journals have moved away from that. In the abstract, you should include the reason for the repot, presenting concerns of the patient, diagnosis, intervention and outcomes.
Key Words: These should be MeSH terms, so select carefully.Introduction: Provide background for your case and why it is important.
Presenting Concerns: Why did the patient seek care? Provide historical information about the patient.Clinical Findings: Provide only those findings which are relevant to the case. No need to provide ling lists of normal findings. Be sure to support your diagnosis with the findings.
Timeline: What was the course of care. A table or figure can help illustrate this quite well.Diagnostic Focus and Assessment: Summarize your diagnostic finding and your clinical reasoning arising from those findings.
Therapeutic Focus and Assessment: Discuss your treatment plan and how it was administered.Follow-up and Outcomes: Summarize the clinical course of the case. How did the patient respond to care? What was the final outcome?
Discussion: What does this all mean? What was learned as a result of publishing the report? What gap in the literature was filled? What other interpretations of the results might be considered? What limitations exist?Patient Perspective: This is a new part of the paper. Where possible and appropriate, the patient should provide a brief narrative of their case to accompany the paper.
Informed Consent: The patient should provide consent and permission for the paperThis is all pretty much what traditionally has been seen in case reports, but this codifies the format, making it easier to know how to organize information and construct a logical flow from it. Please use!
1. Munk N, Boulanger K. ASdaptation of the CARE guidelines for therapeutic massage and bodywork: efforts to improve the impact of case reports. Int J Ther Massage Bodywork 2014;7:32040