A guide to writing a medical case report

Impact case studies and the role they play

The nature of medicine is unpredictable and challenging. Medical students will come across the nature of medicine in the form of patients not adhering to a textbook case. Whether it is a new pathology or a specific reaction to medical intervention not previously known, the nature of medicine makes it necessary to publish the new findings as case reports. The case report has for many centuries and is currently a fundamental way of sharing knowledge to convey the medical experience.

writing case report

However, compared to Original Research (see Types of journal articles), Case Reports do have limitations. Whereas an original article is used to publish full reports of data from research, the goal of a Case Report is to make other researchers aware of the possibility that a specific phenomenon might occur. In so doing, a case report becomes valuable as an educational caveat linking abstract medical knowledge to a particular patient or circumstance. Different areas of medical education such as physiology, pathology, pharmacology, and anatomy are brought together in case reports and help students and doctors to develop a more holistic approach to patients.

Should I write a case report?

A case report often helps to create a deeper understanding of a medical topic. An added side effect of a report is that it acts as a catalyst for academic writing. Skills gained through the development process such as conducting a literature review, structuring a manuscript, submitting to a journal, and revising an article are integral to the advancement of an academic career. Additionally, a published case report is a contribution to medical science, the greater public, and the means of establishing the author’s name in print.

Table 1: Evidence required

  • Evidence from at least one properly randomized controlled trial
  • Evidence from well-designed controlled trials without randomization
  • Evidence from well-designed cohort or case-control analytic studies, preferably from more than one center or research group
  • Evidence from multiple case series with or without intervention or dramatic results in uncontrolled experiments
  • Opinions of respected authorities, based on clinical experience, descriptive studies, and case reports, or reports of expert committees

How do I go about finding a suitable case to report?

As a young medical student knowing when a case is unique or interesting may seem difficult. For this reason, obtaining guidance from senior colleagues will lessen the burden. In situations where information regarding a rare or unusual case is obtained through general discussion, it is worth investigating further to determine the source and the perspective author. In such a situation, offering assistance to prepare the case as a report would not only help senior doctors but allow medical students the opportunity to gain access to specific knowledge.


When you have found a suitable case it is vital to prepare before starting the writing process.

Literature review

A literature review on a medical database such as PubMed, Ovid, or Medline can be used to check if there have been any similar cases; this helps to determine the rarity of the case.

Coordinating with doctors in charge

It is very important to discuss writing a case report with the senior clinician in charge of a patient’s care. Not only must you gain their permission, but they will also help to provide guidance and advice. In addition, it is also worth discussing the case with clinicians of other specialties (such as pathology, radiology, and microbiology) who have played a role in the patient’s care.。

Gaining consent

Review the target journal’s guidelines. It is important. Obtaining consent from the patient to include clinical details or images is extremely important and oftentimes required by the journal. During the consent process, you must explain why you wish to share their case with others, the risks, and the benefits of doing so, and you must answer any questions they may have.

Data collection

When you have done your literature review, communicated with the senior doctor, and gained consent from the patient the development of the case can begin. The data collection phase may involve obtaining medical notes, laboratory results, imaging, and any other relevant material.

How do I structure a medical case report?

The basic structure of a medical case report is as follows:

  • Abstract—This section is read by people trying to decide whether they wish to go on and read your full case report. It is therefore vital to keep it concise (typically under 150 words, see the target journal guidelines) and clear, and to encompass all the important aspects of your case, particularly highlighting what this adds to medical knowledge.
  • Case report—In this section, you are presenting your patient to the reader. This should include a concise history and any relevant examination and investigation findings. It is important to include any relevant negatives based upon the potential diagnoses, but do not clutter this section with unnecessary detail.
  • Discussion—When you have presented the case it is necessary to put it into context in the discussion section. Here you give information about the condition or intervention in question, such as the basic epidemiology, pathophysiology, clinical presentation, investigations, and treatment. As you develop the report it is extremely critical to demonstrate how this particular case has differed from the norm and how this is contributing to medical understanding.

Where can I get my case reports published?

Given the reluctance of many journals to publish case reports these days, where are you to turn when you wish to share your newly written up experience of an interesting case? Fortunately, the vastness of cyberspace has allowed for the development of a new breed of medical journals. A number of online journals such as BMJ Case Reports (www.casereports.bmj.com), Cases Journal (www.casesjournal.com), Radiology Case Reports (www.radiology.casereports.net), and Dermatology Case Reports (https://www.longdom.org/dermatology-case-reports.html ) allow the publication and dissemination of notable case reports.


  1. Student BMJ 2009;17:b5274
  2. National Institute of Health, US National Library of Medicine https://www.ncbi.nlm.nih.gov/pubmed
  3. Heller S. Freud A to Z. Wiley, 2005.

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