Guide

    How to Write a Medical Case Report

    A practical, step-by-step guide for doctors, residents, and medical students who want to publish a clinical case report in a peer-reviewed journal.

    What is a Medical Case Report?

    A medical case report is a detailed, narrative description of a unique or instructive clinical encounter with a patient. It is one of the oldest and most fundamental forms of medical literature, dating back centuries. Despite being considered the lowest level of clinical evidence, case reports remain invaluable for documenting rare diseases, unusual presentations, novel treatments, and unexpected adverse events.

    Case reports serve multiple purposes in medical education and practice. They alert clinicians to new or emerging conditions, provide insights into disease mechanisms, highlight diagnostic and therapeutic challenges, and offer teaching material for trainees. For medical students and junior doctors, publishing a case report is often the first step into academic medicine and research.

    A well-written case report follows a standardized structure — typically including a title, abstract, introduction, case presentation, discussion, and conclusion. Most journals now require adherence to the CARE (CAse REport) guidelines, a 13-item checklist that ensures completeness and transparency. You can use our free case report template to get started quickly.

    7 Steps to Write a Case Report for Journal Publication

    01

    Choose a Noteworthy Case

    Select a case that presents a rare condition, an unusual presentation of a common disease, a novel treatment approach, or an unexpected outcome. The case should add something new to the medical literature.

    Ask yourself: Would a colleague find this case clinically educational? Has a similar case been reported before? If the answer to the first question is yes and the second is no (or very few times), you likely have a publishable case. Common categories include rare diseases, atypical presentations of common conditions, unexpected drug reactions, diagnostic dilemmas, and innovative management strategies.

    02

    Obtain Informed Consent

    Before writing, secure written informed consent from the patient (or their legal guardian). De-identify all personal information — remove names, dates of birth, hospital numbers, and any details that could identify the patient.

    Most journals will not review a case report without documented patient consent. Use a standardized consent form that explicitly states the case will be published in a medical journal. Some journals provide their own consent templates. Even with consent, always de-identify the patient — replace specific dates with relative timelines (e.g., 'Day 3 of admission') and use approximate ages.

    03

    Write the Abstract

    Summarize your case in 150–250 words. Include the background, case presentation, key findings, diagnosis, treatment, and outcome. Many journals require a structured abstract with specific headings.

    A well-written abstract is critical because editors often decide whether to send a manuscript for review based on the abstract alone. Use the IMRaD-like structure: Background (why this case matters), Case Presentation (key clinical details), and Conclusion (the clinical lesson). Avoid abbreviations unless universally understood, and do not include references in the abstract.

    04

    Draft the Introduction

    Provide context for why this case is worth reporting. Briefly review the relevant literature and state the purpose of your report. Keep it concise — 1 to 2 paragraphs is typical.

    Start with a general statement about the disease or condition, narrow down to the specific aspect your case addresses, and end with a statement of purpose. For example: 'Condition X affects approximately Y people worldwide. While the typical presentation includes A and B, our case demonstrates an unusual manifestation of C, which has been reported only Z times in the literature.' Cite 3–5 key references.

    05

    Describe the Case Presentation

    Present the patient's demographics, chief complaint, history of present illness, past medical history, examination findings, investigation results, and clinical course in chronological order.

    This is the core of your report. Organize it chronologically and include: patient demographics (age, sex), presenting symptoms with duration, relevant medical/surgical/family history, physical examination findings, laboratory results (with reference ranges), imaging findings, the diagnostic workup and reasoning, treatment given (with dosages and durations), the clinical course including complications, and follow-up outcomes. Use tables for lab values and figures for imaging when possible.

    06

    Write the Discussion

    Compare your findings with existing literature. Explain what makes this case unique, discuss the differential diagnosis, and highlight the clinical lessons learned. This is the most important section.

    Structure your discussion around these questions: (1) What is already known about this condition? (2) How does your case compare to published cases? (3) What are the possible mechanisms or explanations for your findings? (4) What differential diagnoses were considered and why were they ruled out? (5) What are the limitations of your report? (6) What is the clinical takeaway? Cite at least 10–15 relevant references. Avoid speculation without supporting evidence.

    07

    Add References & Format for Submission

    Cite relevant literature using your target journal's citation style. Format the manuscript according to the journal's author guidelines, including word count limits, figure requirements, and section structure.

    Most medical journals use Vancouver (numbered) or AMA citation style for case reports. Verify the journal's specific requirements for word count (typically 1,500–3,000 words), number of references (usually 15–30), number of figures/tables allowed, and abstract format. Use a reference manager or CasePublish's built-in PubMed search to add citations accurately.

    Common Mistakes to Avoid in Case Report Writing

    Even experienced clinicians make these errors when writing their first case reports. Avoiding these common pitfalls will significantly improve your chances of acceptance.

    ❌ Writing a case report about a common presentation

    ✅ Ensure your case has a unique clinical lesson, rare finding, or novel approach that adds to the literature.

    ❌ Weak or missing discussion section

    ✅ The discussion should be the longest section. Compare with at least 10 published cases and explain what's unique about yours.

    ❌ No differential diagnosis

    ✅ Always discuss what other diagnoses were considered and explain why they were ruled out with evidence.

    ❌ Missing patient consent documentation

    ✅ Journals will reject manuscripts without documented consent. Obtain and mention it in the manuscript.

    ❌ Submitting to the wrong journal

    ✅ Research your target journal's scope, case report word limits, and recent publications before submitting.

    ❌ Poor follow-up data

    ✅ Include follow-up outcomes — reviewers want to know what happened to the patient after treatment.

    Case Report vs Case Series — What's the Difference?

    A case report describes a single patient encounter in detail — covering history, diagnosis, treatment, and outcomes. It is ideal for documenting rare findings, unusual presentations, or novel therapeutic approaches.

    A case series describes three or more patients with a similar condition, treatment, or outcome. It provides slightly stronger evidence because it can identify patterns and trends across multiple cases.

    AspectCase ReportCase Series
    Patients13+
    Evidence LevelLevel 5Level 4
    Word Count1,500–3,0002,500–5,000
    DifficultyEasierMore complex
    Best ForRare/unique findingsIdentifying patterns

    Which Journals Accept Case Reports?

    Many peer-reviewed journals publish case reports. Some are dedicated case report journals, while others accept case reports as a specific article type. Here are popular options across specialties:

    JournalIndexingAPC
    BMJ Case ReportsPubMed, ScopusInstitutional / ~$200
    CureusPubMedFree
    SAGE Open Medical Case ReportsPubMedFree
    Journal of Medical Case ReportsPubMed, Scopus~$1,290
    Oxford Medical Case ReportsPubMed~$600
    Radiology Case ReportsPubMed~$500

    Use CasePublish's Journal Recommendation Engine to find the best-fit journal based on your specialty, keywords, and case type.

    Frequently Asked Questions

    What is a medical case report?+
    A medical case report is a detailed, structured description of an interesting or unusual clinical case encountered in medical practice. It typically covers the patient's history, diagnosis, treatment, and outcomes, and is published in a peer-reviewed journal to share clinical lessons, rare findings, or novel treatment approaches with the medical community. Case reports are the smallest publishable unit of clinical evidence.
    How long should a medical case report be?+
    Most medical case reports are between 1,500 and 3,000 words, excluding references. The abstract is typically 150–250 words. However, word limits vary by journal — some allow up to 4,000 words while others restrict to 1,500. Always check your target journal's author guidelines for specific requirements.
    How do I choose a journal for my case report?+
    Consider these factors: (1) Does the journal publish case reports in your specialty? (2) Is it indexed in PubMed or Scopus? (3) What is the article processing charge (APC)? (4) What is the typical turnaround time? Journals like BMJ Case Reports, Cureus, and SAGE Open Medical Case Reports are popular choices. CasePublish's Journal Recommendation Engine can help you find the best-fit journal.
    Do I need patient consent to publish a case report?+
    Yes, written informed consent from the patient (or their legal guardian) is required by virtually all medical journals. Even with consent, you must de-identify the patient by removing names, specific dates, hospital numbers, and any information that could reveal their identity. Some journals provide their own consent forms.
    What are CARE guidelines?+
    CARE (CAse REport) guidelines are a 13-item checklist developed in 2013 to standardize and improve the quality of case report writing. They cover every section from title to patient consent and are now required by many journals. Following CARE guidelines increases your chances of acceptance. You can view the full checklist on our CARE Guidelines Checklist page.
    Can medical students write and publish case reports?+
    Absolutely. Case reports are one of the most accessible forms of medical publication for students. Many students publish their first case report during clinical rotations. Having a senior clinician as a co-author or mentor is recommended for guidance on clinical accuracy and the publication process.
    How long does it take to publish a case report?+
    The timeline varies by journal. Writing typically takes 2–4 weeks. After submission, peer review usually takes 2–8 weeks. If revisions are requested, expect another 1–2 weeks for revisions and 2–4 weeks for re-review. Total time from writing to publication is typically 2–6 months.
    What is the difference between a case report and a case series?+
    A case report describes a single patient case in detail, while a case series describes multiple patients (usually 3 or more) with a similar condition or treatment. Case series provide slightly stronger evidence because they show patterns across multiple patients, but case reports are easier to write and still valuable for rare or unique findings.

    Related Resources

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