This is the part of the paper in which you introduce the raw data.

First describe the complaint that brought the patient to you. It is often useful to use the patient’s own words. Next, introduce the important information that you obtained from your history-taking. You don’t need to include every detail – just the information that helped you to settle on your diagnosis. Also, you should try to present patient information in a narrative form – full sentences which efficiently summarize the results of your questioning. In your own practice, the history usually leads to a differential diagnosis – a short list of the most likely diseases or disorders underlying the patient’s symptoms. You may or may not choose to include this list at the end of this section of the case presentation.

The next step is to describe the results of your clinical examination. Again, you should write in an efficient narrative style, restricting yourself to the relevant information. For example, if the patient came in suffering from an acute whiplash injury we probably don’t need to be told that their temperature was normal, and we certainly don’t need to be told that it was 37.0 degrees Celsius. That is not to say that you shouldn’t be taking patients’ temperatures in your practice. We simply mean that such information does not help the case report.

If you are using a named orthopedic or neurological test, it is best to both name and describe the test (since some people may know the test by a different name). Also, you should describe the actual results, since there may be some confusion about what constitutes a “positive” or “negative” result. Similarly, if you are presenting laboratory results, it is useful to provide the lab’s normal values since these may vary.

X-rays or other images are only helpful is they are clear enough to be easily reproduced and if they are accompanied by a legend. Be sure that any information that might identify a patient is removed before the image is provided to the publisher.

At this point, or at the beginning of the next section, you will want to present your working diagnosis or clinical impression of the patient.