Template

    Medical Case Report Template

    A section-by-section template with example text, writing tips, and guidance. Follows the CARE guidelines so your report is ready for journal submission.

    How to Use This Template

    This template follows the structure recommended by the CARE guidelines and is compatible with most medical journals. Each section includes example text you can adapt and guidance on what reviewers expect.

    You can copy the template using the button above and paste it into your word processor, or use CasePublish's interactive editor which has this template built in with AI writing assistance, auto-formatting, and one-click export.

    For a complete walkthrough of the writing process, see our step-by-step guide to writing a case report.

    Template Sections with Examples

    Title

    [Condition/Finding]: A Case Report of [Key Aspect] in a [Patient Demographics]

    Guidance: Include 'case report' in the title. Mention the diagnosis or clinical finding and what makes the case noteworthy. Keep it under 20 words.

    💡 Tips: Good titles are specific and informative. Compare: ❌ 'An Interesting Case' vs ✅ 'Spontaneous Pneumomediastinum in a Young Athlete: A Case Report'. Include the condition, the unique aspect, and patient context.

    Abstract

    Background: [Why is this case worth reporting?] Case Presentation: [Brief demographics, chief complaint, key findings, diagnosis, treatment, and outcome] Conclusion: [Primary clinical lesson learned]

    Guidance: Most journals require 150–250 words. Use a structured format with Background, Case Presentation, and Conclusion.

    💡 Tips: The abstract is your first impression. Editors often decide whether to send for review based on the abstract alone. Be concise but include the essential clinical details. Avoid abbreviations and references.

    Introduction

    [Disease/condition] is characterized by [brief description]. While [common presentation], [rare aspect of this case] has been reported infrequently in the literature. We present a case of [brief case summary] to highlight [clinical significance].

    Guidance: 1–2 paragraphs. Provide context, cite relevant literature, and state why you're reporting this case.

    💡 Tips: Follow the 'funnel' approach: start broad (general information about the condition), narrow down (what's specific about your case), and end with purpose (why you're reporting it). Cite 3–5 key references to establish context.

    Case Presentation

    A [age]-year-old [sex] presented to [setting] with a chief complaint of [symptoms] for [duration]. Past medical history was significant for [relevant history]. On examination, [pertinent findings]. Laboratory investigations revealed [key results]. Imaging showed [findings].

    Guidance: Present in chronological order. Include demographics, history, examination, investigations, diagnosis, treatment, and follow-up.

    💡 Tips: This is the core of your report. Use a chronological narrative. Include specific lab values with reference ranges, imaging findings with modality used, treatment details with dosages and durations, and follow-up outcomes. Use tables for lab data and figures for imaging. Refer to the CARE guidelines for completeness.

    Discussion

    This case illustrates [key finding]. In the existing literature, [similar cases/findings have been described — cite references]. Our case differs in that [unique aspects]. The possible mechanism for [finding] may involve [pathophysiology]. Limitations of this report include [limitations].

    Guidance: Compare with literature, explain what's unique, discuss mechanisms, acknowledge limitations, and state the clinical lesson.

    💡 Tips: The discussion is usually the longest section and the most important for reviewers. Structure it: (1) Summarize your key finding, (2) Compare with published cases (cite 10–15 references), (3) Discuss pathophysiology or mechanisms, (4) Address differential diagnoses considered, (5) Acknowledge limitations, (6) State the clinical takeaway. Avoid speculation without evidence.

    Conclusion

    This case highlights the importance of [clinical lesson]. Clinicians should consider [recommendation] when encountering [scenario]. Further research is warranted to [future direction].

    Guidance: 2–3 sentences. Summarize the main takeaway and any recommendations.

    💡 Tips: Keep it brief and actionable. What should a clinician do differently after reading your case? Avoid repeating the entire case. Focus on the single most important lesson.

    Journal Format Comparison

    Different journals have different formatting requirements. Here's a comparison of popular case report journals to help you choose and format your manuscript correctly.

    JournalWord LimitAbstractRef. Style
    BMJ Case ReportsUp to 3,000Structured (Background, Case, Discussion)Vancouver
    CureusNo strict limitUnstructured, 250 words maxVancouver
    Journal of Medical Case ReportsUp to 3,000Structured (Background, Case, Conclusion)Vancouver
    SAGE Open Medical Case ReportsUp to 3,000StructuredAMA

    CasePublish can automatically format your manuscript for 50+ journals. Try it free →

    General Writing Tips for Case Reports

    Write in the past tense

    Clinical events happened in the past. Use past tense throughout the case presentation. Only use present tense in the discussion for established medical facts.

    Use a chronological timeline

    Present events in the order they occurred. Consider adding a visual timeline table — many reviewers find this helpful and the CARE guidelines recommend it.

    Be specific with clinical data

    Instead of "elevated liver enzymes," write "AST 245 U/L (normal: 10–40) and ALT 312 U/L (normal: 7–56)." Specific values add credibility and clinical utility.

    Get a senior co-author

    If you're a student or junior doctor, having an experienced clinician as co-author adds credibility, improves clinical accuracy, and helps navigate the peer review process.

    Proofread and use a checklist

    Before submitting, run through the CARE checklist to ensure completeness. Have a colleague review for clarity and clinical accuracy.

    Frequently Asked Questions

    What format should a case report follow?+
    Most medical case reports follow this structure: Title, Abstract, Introduction, Case Presentation, Discussion, Conclusion, and References. Some journals also require Keywords, Patient Perspective, Learning Points, or an Author Contributions section. The CARE guidelines provide a 13-item checklist that covers all essential elements.
    Can I use this template for any journal?+
    This template follows the widely accepted CARE guidelines structure, which is compatible with most journals. However, you should always check your target journal's specific author guidelines for word limits, abstract format, and section requirements. CasePublish automatically adapts the format when you select a target journal.
    How many references should a case report have?+
    Most case reports include 15–30 references. The introduction typically has 3–5, and the discussion section accounts for the majority. Focus on citing relevant case reports, review articles, and clinical guidelines. Avoid excessive self-citation and ensure all references are recent and directly relevant.
    Should I include images and tables in my case report?+
    Yes, when relevant. Clinical images (CT scans, X-rays, pathology slides, clinical photographs) strengthen your case significantly. Use tables for lab values, timelines, or comparisons with published cases. Most journals allow 3–6 figures/tables. Ensure all images are de-identified and high resolution (300 DPI minimum).
    What is the difference between Vancouver and AMA citation styles?+
    Both are numbered citation styles commonly used in medical literature. Vancouver style (used by ICMJE journals) numbers references in order of appearance and lists up to 6 authors before using 'et al.' AMA (American Medical Association) style is similar but has slight formatting differences in journal abbreviations and author name formatting. Check your target journal's requirements.

    Related Resources

    📖 How to Write a Case Report

    Step-by-step guide from choosing a case to journal submission.

    ✅ CARE Guidelines Checklist

    The complete 13-item checklist for CARE-compliant case reports.

    Write your case report faster

    CasePublish gives you this template as an interactive editor — with AI writing assistance, auto-save, PubMed search, and one-click export to Word or PDF.

    Start Writing — Free