Guidance for reporting a case report or case series

The area of focus and “case report” should appear in the title.

Two to five key words that identify topics in this case report.

What is unique and why is it important?

The patient’s main concerns and important clinical findings.

The main diagnoses, interventions, and outcomes.

What are one or more “take-away” lessons?

Briefly summarize why this case is unique with medical literature references.

De-identified demographic and other patient information.

Main concerns and symptoms of the patient.

Medical, family, and psychosocial history including genetic information.

Relevant past interventions and their outcomes.

Relevant physical examination (PE) and other clinical findings.

Relevant data from this episode of care organized as a timeline (figure or table).

Diagnostic methods (PE, laboratory testing, imaging, surveys).

Diagnostic challenges.

Diagnostic reasoning including differential diagnosis.

Prognostic characteristics when applicable.

Types of intervention (pharmacologic, surgical, preventive).

Administration of intervention (dosage, strength, duration).

Changes in the interventions with explanations.

Clinician and patient-assessed outcomes when appropriate.

Important follow-up diagnostic and other test results.

Intervention adherence and tolerability (how was this assessed)?

Adverse and unanticipated events.

Strengths and limitations in your approach to this case.

Discussion of the relevant medical literature.

The rationale for your conclusions.

The primary “take-away” lessons from this case report.

The patient can share their perspective on their case.

The patient should give informed consent.