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Table 1 The CARE guidelines checklist

From: The CARE guidelines: consensus-based clinical case reporting guideline development

The Narrative: A case report tells a story in a narrative format that includes the presenting concerns, clinical findings, diagnoses, interventions, outcomes (including adverse events), and follow-up. The narrative should include a discussion of the rationale for any conclusions and any take-away messages.
Item name Item no. Brief description
Title 1 The words “case report” (or “case study”) should appear in the title along with phenomenon of greatest interest (eg, symptom, diagnosis, test, intervention)
Keywords 2 The key elements of this case in 2-5 words
Abstract 3 a) Introduction—What does this case add?
   b) Case Presentation:
     - The main symptoms of the patient
     - The main clinical findings
     - The main diagnoses and interventions
     - The main outcomes
   c) Conclusion—What were the main “take-away” lessons from this case?
Introduction 4 Brief background summary of this case referencing the relevant medical literature
Patient Information 5 a) Demographic information (eg, age, gender, ethnicity, occupation)
   b) Main symptoms of the patient (his or her chief complaints)
   c) Medical, family, and psychosocial history—including diet, lifestyle, and genetic information whenever possible, and details about relevant comorbidities including past interventions and their outcomes
Clinical Findings 6 Describe the relevant physical examination (PE) findings
Timeline 7 Depict important dates and times in this case (table or figure)
Diagnostic Assessment 8 a) Diagnostic methods (eg, PE, laboratory testing, imaging, questionnaires)
   b) Diagnostic challenges (eg, financial, language/cultural)
   c) Diagnostic reasoning including other diagnoses considered
   d) Prognostic characteristics (eg, staging) where applicable
Therapeutic Intervention 9 a) Types of intervention (eg, pharmacologic, surgical, preventive, self-care)
     - Administration of intervention (eg, dosage, strength, duration)
     - Changes in intervention (with rationale)
Follow-up and Outcomes 10 a) Summarize the clinical course of all follow-up visits including
     - Clinician and patient-assessed outcomes
     - Important follow-up test results (positive or negative)
     - Intervention adherence and tolerability (and how this was assessed)
     - Adverse and unanticipated events
Discussion 11 a) The strengths and limitations of the management of this case
   b) The relevant medical literature
   c) The rationale for conclusions (including assessments of cause and effect)
   d) The main “take-away” lessons of this case report
Patient Perspective 12 The patient should share his or her perspective or experience whenever possible
Informed Consent 13 Did the patient give informed consent? Please provide if requested