How to Write a Case Report

A case report describes a medical article written to highlight a particular clinical case. For example, a doctor might write about an unusual presentation of a clinical condition, an unexplained set of symptoms that signify an unrecognized disease, or adverse effects from a course of medical treatment. Medical imaging and radiology journals also publish case studies about the novel use of imaging equipment to diagnose diseases.

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What is the Purpose of a Case Report?

Case reports give doctors a chance to exchange information. The substance of the report should be unique, building upon or providing nuance to existing published material. Whether the author writes about rare cases or gives recommendations for improving physical examinations, the report must add to the body of scientific literature on a given topic. No medical journal would publish a case report describing a standard presentation of a well-known disease, diagnosed using the traditional methods. In order to merit publication, a case study must raise important questions or present new solutions.

How is a Case Report Structured?

A case report must be written in a concise, streamlined style. Usually, a case report consists of the following elements:

Title | The title should contain relevant keywords so that readers can find the report through open access search engines like PubMed and Google Scholar

Abstract | In 100 words or less, the author describes the subject of the case report and its high-level findings. Again, this section will appear in a medical literature search, so it should contain as many search terms that relate to the case as possible.

Introduction | This section of the case report explains why the case presentation is unique. Along with a brief description of the case, the introduction contains a justification of why the case warranted special publication as a case study. The author answers the question, “What makes this patient case report of special interest to the medical world?”

Case Description | This section contains a summary of the case and a detailed description of the patient’s medical history. Usually, the author presents the patient’s notes in chronological order: presentation of symptoms, examination, imaging, laboratory results, treatment, diagnosis, and follow-up. All personal information should be removed from the published material. 

Discussion | As in the introduction, the discussion section should reiterate the reason that the case warranted publication. This section provides the author with an opportunity to explain what makes the case unique and share any valuable lessons learned from the case. 

Most case studies also include separate sections for references and figures and tables.

Who Is Qualified to Write a Case Report?

Case reports are usually written by doctors or by medical students. Sometimes, a student prepares a case report, then an attending physician reviews the report and receives a credit as a co-author. Before publishing, the author(s) of the report should obtain the patient’s consent. Often, patient consent is required by law; however, even when it’s not legally required, a consent form helps show that the author has obtained the patient’s permission to publish the report. Most journals and periodicals require informed consent. 

The Case for Case Reports

An article by Zhonghua Sun in the Journal of Medical Radiation Sciences explains how case reports fit into the publication pecking order: “In the hierarchy of evidence-based medicine, randomized controlled trials are placed at the top, superseded by systematic reviews and meta-analyses, followed by prospective experimental trials, then observational studies, case–control studies, and case series at the bottom.” Many journals refuse to publish case studies because they negatively impact their credibility, as measured by “impact factor” rankings. Because case studies don’t receive as much attention as trials and other types of articles, publishers may be hesitant to include them. 

That said, case reporting can be very important to the field of medicine. In an article titled The Process of Writing a Case Report, the authors explain the value of first-hand anecdotes: “While case reports are somewhat falling out of favor within the medical literature community…the things we remember best are often attached to patient stories.” An interesting case report may have the power to inspire further research, new care guidelines, and faster and more accurate diagnoses. 

Publishing Case Reports

Publications each have specific requirements for formatting clinical case reports. Here is a small sampling of the guidelines provided by different journals and periodicals. Before submitting your case report, be sure to adapt the formatting of your report to fit the publisher’s requirements. 

Most journals and periodicals have a peer review process to ensure the quality of any reports they publish. When it comes to peer reviewing a case report, the Journal of Medical Case Reports suggests that editorial feedback should be completed with an eye for novelty, authenticity, ethics, competing interests, impact, and patient consent. Their guidelines explain, “The peer review process is an essential part of ethical and scientific writing.” In addition to editing a manuscript for clarity, peer reviewers must ensure that the clinical information presented in a case report is both honest and ethically obtained. 

Before writing case reports, we recommend taking a look at some examples of the format. The descriptions below have been taken from published case reports, and they link to full-length reports.

Example 1 | Cardiac involvement in malignant lymphoma is one of the least investigated subjects in oncology. This article reports a case of cardiac involvement in Hodgkin’s lymphoma which presented as heart failure.

Example 2 | This is a case report of a 55-year-old male, with COVID-19 pneumonia who has received convalescent plasma as part of a treatment plan which showed significant radiological and clinical improvement post-treatment.

Example 3 | Bullous pemphigoid (BP) is the most frequent autoimmune subepidermal blistering disease of the skin. We report on a BP patient with lesions involving the nail unit, which resulted in a peculiar and as yet rarely recognized complication of BP, pterygium unguis.