Clinical Reports

# 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