Clinical Case Report Guidelines

A case report is a type of research approach where an unexpected or unusual event is documented in depth in a report of findings, clinical course, and prognosis for a specific patient. A review of the literature on other known instances is optional but may be included as well.

The purpose of accepting case studies is to provide more details about investigative research studies that enhance the area of clinical trials.

Case Report Structure

The following sections should be included in your clinical case report:

  • Title
  • Summary
  • Background
  • Case presentation
  • Discussion
  • Conclusion
  • Key takeaways
  • References
  • Figures and videos

Title Requirements

  • Choose a clinical and straightforward title that appropriately expresses the diagnosis and major highlights of the case report.
  • Do not use the words "case report," "review," "rare case," "literature review," or "first case" in the title.
  • Do not use any exclamation marks at the end of the title.
  • Do not mention the patient's age, gender, or race in the title.
  • The title should be concise and not too long.

Summary Section

  • Similar to the abstract of a research article.
  • Summarize all essential information about the case, emphasizing learning points.
  • Word count should not exceed 150 words.
  • Do not include background information.

Background Section

  • Describe the context of the case report, prevalence of the health issue, and provide a clear message.
  • Do not repeat information from the Summary section.

Case Presentation

  • Word count: 1000–2000 words (excluding summary, background, references, figures, and tables).
  • Specify any relevant clinical guidelines or systematic reviews used.
  • Provide a thorough description of presenting characteristics, including medical, social, and familial background.
  • Keep patient and institute information as anonymous as possible.
  • Include medical history, signs and symptoms, adverse events, and clinical examinations (avoid unnecessary details).
  • Describe case findings and factors influencing decisions.
  • Avoid abbreviations for investigational diseases.
  • Present facts clearly, using diagrams, flowcharts, or timelines when helpful.
  • Results can be tabulated or shown in unique graphs/figures (not copied from other publications).
  • Include differential diagnosis, treatment strategy, and follow-up.
  • Ensure a clear and unambiguous conclusion.
  • Sub-headings can be used to organize the Case Presentation section.

Discussion Section

  • Detail pathology, injury triggers, current recommendations, and diagnostic paths.
  • Use original graphics to illustrate procedures.
  • Highlight the key points of the case.
  • Cite up-to-date literature for comparison or differentiation.
  • Ensure proper citation for all external information.
  • Do not copy text, tables, or figures from other publications without permission.
  • Figures demonstrating clinical-pathological relationships are encouraged.

Conclusion

  • Accurately and concisely summarize the main clinical message of the case study.

Key Takeaways

  • Include 3–5 bulleted points highlighting crucial information for readers.

References

  • Include relevant, up-to-date references per AMA style guide.
  • Format references in Times New Roman, size 12, superscripted Arabic numerals.
  • Cite references correctly within the text.

Figures and Videos

  • No limits on representations, but only include those that best explain the case report.
  • Ensure patient anonymity; do not include faces.
  • Images and videos should be colored.
  • Add arrows, annotations, and captions to clearly describe content.
  • Videos: maximum 3–4 minutes, no background music; narration should be clear and easily understood.