The Ulutas Medical Journal p-ISSN 2149-0430 e-ISSN 2149-388X

How to write a case report (with the CARE checklist)

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A case report is a detailed description of the symptoms, signs, diagnosis, treatment and follow-up of one patient. Good case reports are short, honest and easy to check. This guide walks you through deciding whether your case is worth writing up and then through the CARE checklist, which this journal asks authors of case reports to follow (see the Instructions for Authors).

Is my case worth reporting?

Being "interesting to us on the ward" is not enough. A case is usually worth publishing when it teaches other clinicians something they could use. An editorial guide in Heart Views lists the most common reasons for publishing a case:

  • an unexpected association between diseases or symptoms;
  • an unexpected event while observing or treating a patient;
  • findings that shed new light on how a disease or an adverse effect develops;
  • unique or rare features of a disease;
  • a unique treatment approach, or an unusual anatomical variation.

Before you start, search PubMed and other databases for similar cases. If dozens of near-identical reports exist, your report needs a clear new point; say in one sentence what that point is. If you cannot, consider whether the case is better used for teaching than for publication.

The CARE checklist, item by item

CARE is the reporting guideline for case reports. Its 2013 checklist has 13 items. In plain terms:

  1. Title – name the main diagnosis or intervention, followed by the words "case report".
  2. Keywords – two to five terms covering the diagnosis or intervention, including "case report".
  3. Abstract – what is unique about the case, the main findings, diagnoses, interventions, outcomes and the main lesson.
  4. Introduction – briefly, why this case is unique, with references if useful.
  5. Patient information – de-identified demographics, main concerns, relevant medical, family and psychosocial history, and earlier treatments.
  6. Clinical findings – the important examination and clinical findings.
  7. Timeline – the episode of care in order, shown as a table or figure.
  8. Diagnostic assessment – tests used, difficulties, the diagnosis and the alternatives you considered.
  9. Therapeutic intervention – what was given, with dose, strength and duration, and any changes with reasons.
  10. Follow-up and outcomes – outcomes judged by clinician and patient, follow-up results, adherence, tolerability and adverse events.
  11. Discussion – strengths and limitations, relevant literature, the reasoning behind your conclusions, and a short take-away message.
  12. Patient perspective – where possible, the patient's own view of the care received.
  13. Informed consent – the patient's consent, with evidence available if the journal asks.

Download the checklist from the CARE website, fill in the page or line number for each item, and keep it ready for submission.

Title, abstract and keywords

Many readers see only the title and abstract, and databases index them. ICMJE notes that the abstract is the only substantive part of an article indexed in many databases, so it must match the main text exactly. Practical tips:

  • Put the diagnosis or intervention first and end the title with "case report", as CARE recommends and as this journal's Informed Consent page also asks.
  • Do not put the patient's age, town, hospital or dates in the title.
  • In the abstract, state the new point of the case, not only the story.
  • Choose keywords that a colleague would type into a search box, and include "case report" as CARE suggests. For original articles the journal asks for keywords from MeSH, the National Library of Medicine's controlled vocabulary; check the word and keyword limits for case reports in the Instructions for Authors.

Patient consent and anonymity

This journal requires written informed consent for publication from the patient (or a parent, legal guardian or next of kin where the patient cannot consent) before submission, and a statement in the article that consent was obtained. The editors may ask to see the signed form. ICMJE adds that a patient who could be identified should be shown the manuscript before it is published.

Remove anything that could identify the patient: names, initials, hospital or record numbers, exact dates and recognisable images. ICMJE warns that covering only the eyes in a photograph does not protect anonymity. Our separate guide on patient consent for case reports explains the details, including KVKK and GDPR.

Common reasons for rejection

Most problems we see are avoidable. Before you submit, check that your manuscript does not fall into one of these traps, each of which conflicts with the journal's published rules:

  • No clear new point. The discussion retells the case without saying what readers should learn.
  • Missing consent statement, or consent from the wrong person.
  • Identifiable details in the text, tables or images, including dates and hospital names.
  • CARE items left out, especially the timeline, follow-up and the diagnoses that were considered.
  • Overstated conclusions. One patient cannot prove that a treatment works; describe what happened and suggest what should be studied.
  • Text copied from earlier reports. Every submission is screened for similarity; paraphrase and cite (see the Plagiarism Policy).
  • References in the wrong style. The journal uses Vancouver style; see our guide with examples.

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