Guidelines for writing patient case report manuscripts

Guidelines for writing patient case report manuscripts

(The following checklist is comprehensive; some items may not apply to all types of case reports.)

Patient case presentation

 Describe the case in a narrative form.

 Provide patient demographics (age, sex, height, weight, race, occupation).

 Provide patient identifiers (date of birth, initials).

 Describe the patient’s complaint.

 List the patient’s present illness.

 List the patient’s medical history.

 List the patient’s family history.

 List the patient’s social history.

 List the patient’s medication history before admission and throughout the case report.

 Ensure that the medication history includes: herbals, vaccines, depot injections, and nonprescription medications

 List each drug’s name, strength, dosage form, route, and dates of administration.

 Verify the patient’s medication adherence.

 List the patient’s drug allergy status, including the name of the drug (brand or generic) and the date and type of reaction.

 List the patient’s adverse drug reaction history and the dates of the reaction.

 Provide the patient’s dietary history.

 Provide pertinent findings on physical examination.

 Provide pertinent laboratory findings that support the case.

 List the completed diagnostic procedures that are pertinent and support the case.

 Paraphrase the results of the diagnostic procedures.

 Provide photographs of histopathology, roentgenograms, electrocardiograms, skin manifestations, or anatomy as they relate to the case.

 Obtain permission from the patient to use the patient’s photographs, or follow institutional guidelines.

 Provide the patient’s events in chronological order.