Clinical Case Report Template

Title

[Insert descriptive title that includes "Case Report" or "Case Study" and indicates the clinical focus]

Example: Unusual Presentation of Acute Appendicitis in an Elderly Patient: A Case Report

Author Information

[Author names, affiliations, ORCID IDs]

Corresponding Author:
[Name]
[Email]
[Institution]

Keywords

[2-5 keywords, preferably MeSH terms]

Example: Appendicitis, Atypical presentation, Elderly, Diagnostic imaging

Abstract

Introduction

[What is unique about this case? Why is it worth reporting? 1-2 sentences]

Patient Concerns

[Primary symptoms and chief complaint]

Diagnosis

[Final diagnosis, how it was reached]

Interventions

[Key treatments provided]

Outcomes

[Clinical outcome and follow-up status]

Lessons

[Main takeaway messages for clinicians]

Word count: [150-250 words]

Introduction

[Background information - 2-4 paragraphs]

Paragraph 1: Background on the condition

• Epidemiology of the condition
• Typical clinical presentation
• Standard diagnostic approach
• Current treatment guidelines

Paragraph 2: Why this case is novel

• What makes this case unusual or important
• Gap in medical knowledge addressed
• Literature review showing rarity or uniqueness
• Clinical significance

Paragraph 3: Objectives

• Purpose of reporting this case
• Learning points to be highlighted

Patient Information

Demographics:

• Age: [e.g., "A 72-year-old" or "A woman in her 70s"]
• Sex: [Male/Female]
• Ethnicity: [if relevant to case]
• Occupation: [if relevant]

Medical History:

• Past medical history: [chronic conditions]
• Past surgical history: [prior surgeries]
• Family history: [relevant family history]
• Social history: [tobacco, alcohol, occupation, living situation]

Medications:

• Current medications: [list with doses]
• Allergies: [drug allergies and reactions]

Presenting Symptoms:

• Chief complaint: ["Patient's words" or clinical presentation]
• Duration of symptoms
• Severity and characteristics
• Associated symptoms
• Relevant review of systems

Clinical Findings

Physical Examination:

• Vital signs: [T, BP, HR, RR, SpO2]
• General appearance: [overall state]
• Systematic examination by organ system:
  • HEENT: [findings]
  • Cardiovascular: [findings]
  • Respiratory: [findings]
  • Abdomen: [findings]
  • Neurological: [findings]
  • Other relevant systems: [findings]

Pertinent Negatives: [Important negative findings]

Timeline

Date/Time	Event
[Day -X or Date]	[Initial symptom onset]
[Day 0 or Date]	[Presentation to healthcare]
[Day 0 or Date]	[Initial evaluation and tests]
[Day X or Date]	[Diagnosis confirmed]
[Day X or Date]	[Treatment initiated]
[Day X or Date]	[Hospital discharge or follow-up]
[Month X or Date]	[Long-term follow-up]

Note: Use relative days (Day 0, Day 1) or approximate dates (Month 1, Month 3) to protect patient privacy

Diagnostic Assessment

Initial Diagnostic Workup

Laboratory Tests:

Test	Result	Reference Range	Interpretation
[Test name]	[Value with units]	[Normal range]	[High/Low/Normal]

Imaging Studies:

• [Modality] ([Date]): [Key findings]
• [Include images if applicable, with labels and arrows pointing to key findings]

Other Diagnostic Procedures:

• [Procedure name] ([Date]): [Findings]

Differential Diagnosis

Diagnoses Considered:

1. [Primary differential]
   • Supporting evidence:
   • Evidence against:
2. [Alternative diagnosis]
   • Supporting evidence:
   • Evidence against:
3. [Additional differentials as appropriate]

Diagnostic Challenges

[Describe any difficulties in reaching the diagnosis]

• Atypical presentation
• Misleading initial findings
• Diagnostic delays
• Complex decision-making

Final Diagnosis

Confirmed Diagnosis: [Final diagnosis with ICD-10 code if applicable]

Diagnostic Reasoning: [Explain how diagnosis was reached, key diagnostic features, confirmatory tests]

Therapeutic Intervention

Treatment Approach

Initial Management:

• [Immediate interventions]
• [Supportive care]
• [Monitoring]

Definitive Treatment:

1. Pharmacological Interventions:

   • [Drug name]: [Dose, route, frequency, duration]
   • Indication: [Why prescribed]
   • Response: [Patient response to treatment]

2. Procedural/Surgical Interventions:

   • [Procedure name] performed on [date/day]
   • Indication: [Why performed]
   • Technique: [Brief description]
   • Findings: [Intraoperative or procedural findings]
   • Complications: [Any complications or none]

3. Other Interventions:

   • [Physical therapy, dietary modifications, etc.]

Alternative Treatments Considered: [Other treatment options that were considered and why they were not pursued]

Changes to Interventions: [Any modifications to treatment plan]

• Date of change:
• Reason for change:
• New intervention:

Follow-up and Outcomes

Immediate Outcome: [Outcome during hospitalization or initial treatment period]

• Clinical response:
• Laboratory or imaging follow-up:
• Complications:
• Length of hospitalization (if applicable):

Short-term Follow-up: ([Timeframe, e.g., 1 month])

• Clinical status:
• Follow-up tests:
• Adherence to treatment:
• Any issues or concerns:

Long-term Follow-up: ([Timeframe, e.g., 6 months, 1 year])

• Clinical status:
• Recovery or resolution:
• Functional status:
• Quality of life:
• Recurrence or complications:

Patient-Reported Outcomes: [Symptoms, quality of life, patient satisfaction]

Discussion

Paragraph 1: Summary and Significance [Briefly summarize the case and state its significance]

Paragraph 2: Literature Review [Review similar cases in the literature]

• Number of similar cases reported
• Comparison to this case
• What is novel about this case
• [Cite relevant references]

Paragraph 3: Clinical Implications [What can clinicians learn from this case?]

• Recognition of atypical presentations
• Diagnostic pearls
• Treatment considerations
• When to consider this diagnosis

Paragraph 4: Pathophysiology or Mechanism (if applicable) [Explain underlying mechanism, why this occurred, contributing factors]

Paragraph 5: Strengths and Limitations [Acknowledge limitations of case report]

• Single case report limitations
• Cannot establish causation
• Generalizability concerns
• Strengths of comprehensive evaluation

Paragraph 6: Future Directions [Unanswered questions, areas for future research]

Learning Points

• [Point 1: Concise, actionable clinical lesson]
• [Point 2: Key diagnostic or treatment pearl]
• [Point 3: When to consider this diagnosis]
• [Point 4: (optional) Additional takeaway]

Patient Perspective

[Optional but encouraged: Patient's own description of experience, in their own words if possible]

"[Patient quote describing their experience, symptoms, treatment, or outcome]"

[Or narrative description of patient's perspective, impact on quality of life, satisfaction with care]

Informed Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

[OR if patient deceased/unable to consent:]

Written informed consent was obtained from the patient's next of kin for publication of this case report, as the patient was deceased [or unable to provide consent due to...] at the time of manuscript preparation.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Funding

This case report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

[OR: This work was supported by [funding source and grant number]]

Acknowledgments

[Acknowledge contributors who do not meet authorship criteria, providers who cared for patient, etc.]

References

[Format according to journal requirements - typically AMA, Vancouver, or APA]

1. [First reference - Author(s). Title. Journal. Year;Volume(Issue):Pages.]
2. [Second reference...]

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CARE Checklist Completion

Use the CARE checklist to ensure all required elements are included:

• Title includes "case report"
• Keywords provided (2-5)
• Structured/unstructured abstract
• Introduction with background and novelty
• Patient demographics (de-identified)
• Clinical findings
• Timeline
• Diagnostic assessment
• Therapeutic interventions
• Follow-up and outcomes
• Discussion with literature review
• Patient perspective (if possible)
• Informed consent statement
• All 18 HIPAA identifiers removed
• References formatted correctly
• Figures/tables labeled and referenced
• Word count within journal limits

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De-identification Checklist

Verify all HIPAA identifiers removed:

• Names (patient, family, providers)
• Geographic locations smaller than state
• Exact dates (use year only or relative time)
• Phone numbers
• Email addresses
• Medical record numbers
• Account numbers
• License numbers
• Device serial numbers
• URLs
• IP addresses
• Biometric identifiers
• Full-face photos (cropped or blurred)
• Any other identifying information

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Notes:

• Adapt this template to your specific journal's requirements
• Check word count limits (typically 1500-3000 words)
• Follow journal's reference style
• Include institutional review/ethics exemption if applicable
• Consider attaching CARE checklist when submitting