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Case Report Grading Rubric
Case reports represent a detailed case presentation of an interesting patient that you have
seen during your clinical training. These reports should be appropriately referenced using
APA style and contain the components listed below. Each Case report is worth 30 points
towards your rotation grade.
Abstract
Thoroughly covers salient facts of case. Raises issues related to natural history of the
6
5
2
0
disease, diagnostic or management issues that the particular presentation raises
Covers salient facts related to case. Misses minor issues related to natural history of the
disease, diagnostic or management issues that the particular presentation raises
Missing several significant facts related to case. Discussion does not include essential
elements related to diagnosis or management essential to demonstrate sound
understanding required by clinicians
Missing major components of the case
Case Report
6
5
2
0
Concisely covers essential items of patient history, physical exam, appropriate diagnostic
studies, differential diagnosis, and therapeutic plan implemented
Covers the majority of essential items in patient history, PE, diagnostic studies,
differential diagnosis and therapeutic plan. Missing minor points salient to the current case
Missing some essential items in patient history, PE, diagnostic studies, differential
diagnosis and therapeutic plan.
Missing major components of history, PE, studies, differential diagnosis, or management
plan
Discussion
6
5
2
0
Thorough concise discussion of the salient features of the case including a detailed
reporting of the elements of this case that makes it unique, interesting or difficult to
diagnose or manage. Uses medical vocabulary appropriately
Thorough discussion of case. Either missing minor components or non concise discussion.
Discussion missing major components of case. Still demonstrates fair understanding of the
salient points.
Discussion fails to demonstrate an understanding of the unique nature of this disorder.
Medical vocabulary used inappropriately or over-reliance on lay terminology.
Summary
6
5
2
0
Concise summary statement that summarizes critical elements of information recorded
above.
Summary inclusive however could be more concise and clear
Summary does not include critical elements of case
Summary fails to demonstrate student knowledge of critical elements of case
References
6
APA format followed. Current resources from reliable sources including journal articles,
web resources and current reference texts including ACP medicine online etc
Minor deviations from APA style. Resources current and reflect current research.
APA format not utilized. Resources dated and do not reflect current resource materials
References do not reflect current research.
5
2
0
Maximum Points-30
Your case reports should contain the following components:
1. Abstract: 250 words or less
2. Case report: Chronological review of case clinical presentation: history
and
physical exam, diagnostic studies, treatment and clinical course including:
 CHIEF COMPLAINT
 HISTORY OF PRESENT ILLNESS
 PHYSICAL EXAMINATION
 LABORATORY & OTHER DIAGNOSTIC FINDINGS (X ray,
MRI, CT
scans, biopsy, etc.)
 CLINICAL COURSE
3. The following questions must be answered in the case report
 What is the differential diagnosis?
 What additional laboratory data or investigations would be
helpful in
arriving at a diagnosis in this patient?
4. Discussion: Detailed discussion of the case being presented including
the
following:
 clinical and laboratory features of the disorder (including
disease
course if applicable)
 Diagnosis and differential diagnosis
 Therapeutic options
 Final diagnosis
5. Summary or conclusions
6. References –APA Style
Case reports should be limited to four type written pages including references
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