Submission Form

Please complete the submission form by January 13, 2012. Notifications will be sent February 15, 2012.

* 1. Demographic Information:

* 2. Indicate if you are (select one):

* 3. Case Report Format:
Age of patient, chief complaint, detailed history of the present illness, relevant past, family, social history, positive ROS, relevant physical findings, relevant lab results, differential diagnosis, and any procedures performed. Include the final diagnosis (which will be withheld from the panelists).

Your submission should be no more than 600 words. You are encouraged to include imaging studies and photographs to illustrate your presentation. If you have imaging studies and/or photographs you would like to submit to supplement your case report please email the digital files to with your name and contact information in the email.

All patient identifiers or other identifying information MUST BE REMOVED.