Identify the diagnosis or intervention of primary focus, followed by the words "case report." The title is the one field every database indexes — a title that hides the design ("An unusual presentation of a common problem") costs the report its findability and is flagged by editors immediately. Name the condition, name the design.
Provide two to five key words that identify the diagnoses or interventions in the report — including "case report" itself. Align them with MeSH vocabulary where possible: key words are what indexing services and other clinicians searching the literature actually use to find the case.
Structured or unstructured per the journal, the abstract must cover four things: what is unique about this case and what it adds to the literature; the patient's main symptoms and important clinical findings; the main diagnoses, therapeutic interventions, and outcomes; and the principal take-away lesson. An abstract that narrates the story but never states what the case adds is the most common abstract failure.
One or two paragraphs summarizing why this case is unique, with references to the relevant medical literature. The introduction is not a mini-review of the condition — it exists to establish the gap this case fills: a novel presentation, an unreported drug reaction, a diagnostic pitfall, an unexpected treatment response.
De-identified demographic and other patient-specific information; the patient's primary concerns and symptoms; medical, family, and psychosocial history including relevant genetic information; and relevant past interventions with their outcomes. De-identification is a floor, not a courtesy — direct identifiers and identifying combinations (rare condition + named hospital + exact dates) must be removed or generalized.
Describe the significant physical-examination findings and other important clinical findings. Pertinent negatives count: the examination findings that were absent are often what make the diagnostic reasoning in item 8 auditable. Findings should be specific enough for a clinician to reconstruct the examination.
Present the historical and current information from this episode of care organized as a timeline — a figure or table with dates or intervals for symptom onset, presentation, diagnostic milestones, interventions, and follow-up. The timeline is the most distinctive CARE item and the most frequently missing one: prose scattered with "eventually" and "several months later" does not satisfy it.
Four parts: the diagnostic methods used (examination, laboratory testing, imaging, surveys); the diagnostic challenges encountered (access, financial, cultural, or language barriers); the diagnosis reached — including the other diagnoses considered and how they were excluded; and prognosis where applicable, such as staging in oncology. A stated diagnosis without the differential that was considered is asserted, not shown.
09Therapeutic intervention
Report the types of intervention (pharmacologic, surgical, preventive, self-care), the administration of each — dosage, strength, duration, frequency — and any changes to the intervention, with the rationale for each change. "The patient was started on antibiotics" is not reportable information; drug, dose, route, and duration are.
Report clinician-assessed and, where available, patient-assessed outcomes; important follow-up diagnostic and other test results; intervention adherence and tolerability, and how these were assessed; and any adverse or unanticipated events. An outcome without a follow-up interval ("the patient recovered") is uninterpretable — state when, relative to the timeline, each outcome was measured.
Four parts: a scientific discussion of the strengths and limitations of this case report; discussion of the relevant medical literature, with references; the scientific rationale for any conclusions — including an assessment of possible causes; and the primary take-away lessons in a single concluding paragraph. This is where case reports most often overreach: a single case can generate a hypothesis about causation, but it cannot establish one.
The patient should share their perspective on the treatment they received, in one to two paragraphs — in their own words where possible; a parent or guardian may provide it when the patient cannot. This item is unique to CARE among the major reporting guidelines, and it is routinely omitted. Journals that enforce CARE will return the manuscript for it.
Did the patient give informed consent for publication? State it explicitly, and be prepared to provide the signed form if the journal requests it. Consent for publication is separate from de-identification and separate from consent to treatment. If the patient has died, consent is sought from next of kin; for minors, from a parent or guardian. Without this statement, most journals will not send the report to review at all.