How to Write a Professional Medical Case Report

case report

The Cornerstone of Medical Knowledge – Understanding the Power of Case Reports

A medical case report is a detailed account of an individual patient's symptoms, signs, diagnosis, treatment, and follow-up, typically describing an unusual or novel occurrence ^1^. These reports are a cornerstone of medical progress, contributing unique clinical experiences to the medical literature that might not be captured in larger studies ^1^. Documenting these exceptional cases is crucial for several reasons:

Highlighting Rare Diseases^2^. Case reports can meticulously describe the clinical presentation, diagnostic process, and treatment outcomes of rare diseases, providing valuable references for other clinicians who may encounter similar cases.
Describing Unusual Presentations of Common Diseases^2^. Even common diseases can manifest with atypical symptoms or signs. Case reports document these unusual presentations, helping to broaden clinicians' awareness of the diverse ways diseases can present.
Reporting Unexpected Events or Adverse Reactions to Treatment^1^. Case reports are a vital avenue for the early identification and documentation of adverse drug reactions, medical device malfunctions, or other unexpected medical events, contributing to patient safety.
Detailing Unusual Combinations of Diseases or Conditions^2^. When patients present with multiple co-occurring conditions or rare complications, case reports can provide a comprehensive description and analysis, enhancing understanding of complex medical scenarios.
Presenting Diagnostic Dilemmas or Uncertain Cases^2^. Some cases pose significant diagnostic challenges. Case reports can detail the thought process behind differential diagnoses, the investigations undertaken, and the eventual diagnostic conclusion, offering insights for colleagues.
Discussing Challenges in Treatment or Management^2^. For cases where treatment is difficult or management is complex, case reports can share the strategies employed, the difficulties encountered, and the ultimate outcomes, fostering the exchange of clinical experience.
Sharing the Personal Impact of Illness or Treatment^1^. Case reports sometimes focus on the impact of a disease or its treatment on a patient's personal life and social functioning, providing a more holistic understanding of the burden of illness.
Presenting New Insights into a Disease or Condition^2^. Through in-depth analysis of a case, reports may reveal new disease mechanisms, pathophysiological processes, or prognostic factors, advancing medical science.
Documenting Anatomical Variations^2^. Rare anatomical variations can present unique challenges or manifestations in clinical practice. Case reports documenting these variations help to raise awareness among clinicians.
Illustrating Novel Theories or Challenging Existing Ones^1^. Some case reports may propose new medical theories based on unique clinical observations or challenge existing theories, stimulating further research.
Showcasing Cost-Effective Approaches or Alternative Strategies^3^. In settings with limited resources, case reports can share experiences with innovative and cost-effective diagnostic or treatment methods.
Raising Awareness of Uncommon Diseases^3^. Through case reports, awareness of rare diseases within the medical community can be increased, leading to earlier diagnosis and appropriate management.

The impetus to write a case report often stems from encountering a unique clinical experience that can broaden the understanding of medical phenomena and potentially improve patient care. When healthcare professionals encounter a case that deviates from the norm or presents a diagnostic or therapeutic challenge, documenting it as a case report allows others to learn from that experience. This sharing of collective knowledge contributes to the evolution of medical understanding and best practices.

Step 1: Identifying a Compelling Case – Criteria for a Reportable Case

scifocus

By using Scifocus's tool, Selecting a case that is worth writing up is crucial. Here are some key criteria to consider:

Novelty and Uniqueness: The case should present a novel or previously unreported aspect of a disease, treatment, or diagnosis ^1^. Cases that simply reiterate known information are unlikely to be impactful. The value lies in introducing a new perspective or finding. Medical journals prioritize publishing information that expands the existing body of knowledge. A case report detailing an entirely new disease, a rare side effect of a known medication, or an innovative diagnostic approach would be considered highly novel.
Importance and Impact: The case should have the potential to contribute to the medical literature, influence clinical practice, or generate hypotheses for future research ^1^. Even if not entirely novel, a case may be significant if it highlights an important clinical lesson or challenges existing assumptions. For instance, a case report might show an unexpected benefit of a treatment in a specific patient subgroup, or it could raise concerns about the safety of a widely used intervention. Such findings can prompt further investigation and potentially alter clinical guidelines.
Clarity of Narrative: The case should have a clear and well-defined sequence of events, investigations, and outcomes that can be presented logically ^2^. It is difficult for readers to learn from a convoluted or poorly documented case. A strong case report unfolds like a story, with a clear beginning (the patient's presentation), middle (the investigations and treatment), and end (the outcome). This logical flow ensures that readers can easily follow the clinical reasoning and the lessons learned.
Potential Learning Points: Consider what other medical professionals can learn from the case ^2^. Does it offer a unique diagnostic challenge, a novel treatment strategy, or an important patient management experience? The educational value of a case is paramount. It should provide insights that can be applied to future clinical scenarios. For example, a case report might highlight a subtle but crucial diagnostic clue that could help other clinicians identify the condition earlier. Alternatively, it might showcase a successful approach to managing a complex or rare disease that others can emulate.
Ethical Considerations: Ensure that the case can be reported while maintaining patient privacy and obtaining informed consent ^1^. Ethical reporting is non-negotiable in medical publications. Before embarking on writing, it is essential to consider whether the case can be presented without revealing the patient's identity and whether the patient (or their legal guardian) has given explicit consent for the case to be published.

Step 2: Structuring Your Narrative – Essential Components of a Medical Case Report

A well-structured case report is essential for effectively communicating information. Here are the key components typically included in a medical case report:

I. Title: The First Impression – Crafting a Clear and Informative Title

The title should be concise and clearly reflect the content of the article ^4^. Ideally, the title should be between 10 and 12 words in length ^3^. Always check the target journal's specific word or character limits. The title should highlight the unique aspect of the case ^3^ and use strong action verbs to convey the core message of the report ^4^. If required by the target journal, include the phrase 'case report' in the title ^4^. Avoid weak opening phrases, jargon, and uncommon abbreviations ^3^. To better determine the title, consider writing the abstract first and then extracting keywords and phrases from it to construct the title ^3^. A well-crafted title is crucial for attracting readers and ensuring the case report is easily discoverable in medical literature databases. For example, 'A Novel Presentation of Guillain-Barré Syndrome Mimicking Acute Stroke: A Case Report' is more informative and engaging than a generic title like 'Case Report.' Including keywords related to the main aspects of the case (Guillain-Barré syndrome, acute stroke, novel presentation) improves its visibility in search results.

II. Abstract: A Snapshot of the Case – Summarizing Key Aspects

The abstract is a brief summary of the case report's content ^10^, typically shorter than abstracts for other types of articles, with word limits often ranging from 100 to 150 words ^1^. Always check the target journal's specific word limit. The abstract should be unstructured, pose the clinical question or diagnostic dilemma ^10^, and provide key information including the chief complaint, diagnosis, intervention, and outcome ^9^. It should also highlight the novelty or importance of the case ^1^ and state the main 'take-home' message ^9^. The abstract is often the first part readers encounter, so it must be concise yet comprehensive enough to convey the essence of the case and its significance. A good abstract quickly informs the reader about the patient's main problem, how it was addressed, and the key findings or lessons learned. This helps readers quickly determine if the case report is relevant to their interests.

III. Introduction: Setting the Stage – Providing Context and Rationale

The introduction should be brief and immediately capture the reader's interest ^10^. Provide background information on why the case is worth reading and publishing ^10^, and state the focus of the case report (e.g., 'We report a case of...') ^10^. Articulate the significance or importance of the case ^3^, describing whether the case is unique or presents an unusual aspect. The introduction should include a focused literature review to support the value of the case ^10^, briefly summarizing relevant literature ^9^ and explaining what the case report adds to the medical literature ^9^. Also, describe the guiding or teaching points that enhance the value of the case ^3^. The introduction typically ends with a one-sentence description of the patient and the basic condition ^1^. The introduction should place the case within the context of existing medical literature and clearly state the rationale for reporting this particular case. By providing background information on the disease or condition and citing relevant studies, the introduction demonstrates the authors' understanding of the existing knowledge and highlights how the current case adds to, contradicts, or presents a unique perspective.

IV. Case Presentation: The Heart of the Report – Detailed Account of the Patient's Journey

Provide a detailed description of the patient's demographics (age, sex, race, occupation – de-identified) ^8^ and present the chief complaint ^9^. Include relevant medical history: past surgical history, family history, and medication history ^9^. Describe the history of the present illness in chronological order ^3^, including relevant physical examination findings ^9^. All pertinent negative findings should also be included ^10^. Describe any relevant prior interventions and their outcomes ^8^. Consider using tables or figures to correlate assessments, diagnoses, and interventions ^9^. This section provides a comprehensive and detailed account of the patient's clinical presentation, allowing the reader to understand the context of the case. By presenting the information chronologically, from the initial presentation to the relevant history and examination findings, this section paints a clear picture of the patient's clinical course. The inclusion of pertinent negative findings is also important as it helps to narrow down the differential diagnoses.

V. Observations and Investigations: Unveiling the Evidence – Diagnostic Workup

Detail the results of pathological examinations and other investigations (laboratory tests, imaging studies, etc.) ^1^. Present the diagnostic assessment and reasoning, including other diagnoses considered and challenges encountered ^9^. Include prognostic features, if applicable ^9^. Use tables and figures to present findings chronologically or to compare observations across different methods ^10^. Ensure all abbreviations in legends are expanded ^9^. For surgical and pathological specimens, provide a comprehensive summary of the surgical procedure and a detailed pathologist's report, if relevant ^10^. This section provides the objective evidence that supports the diagnosis and guides the treatment plan. Presenting the investigation results clearly and concisely allows the reader to understand the diagnostic process and the rationale behind the final diagnosis. Tables and figures are particularly useful for summarizing complex data or illustrating key findings from imaging studies.

VI. Diagnosis: The End of the Diagnostic Journey

Clearly state the final diagnosis and briefly reiterate the key findings that led to this conclusion. This section provides a definitive identification of the patient's condition. After presenting the history, examination findings, and investigations, this section clearly states the diagnosis, providing a crucial reference point for the subsequent discussion.

VII. Treatment: Intervention Strategies – Methods and Duration

Describe the type of intervention, detailed methods, and duration ^1^, and explain the rationale and expected outcomes of the chosen intervention ^1^. Mention other concurrent interventions, if applicable ^9^. This section outlines the therapeutic approaches taken to manage the patient's condition. By detailing the specific treatments administered, including dosages, duration, and any other relevant aspects, this section allows the reader to understand the management strategies employed and potentially apply them to similar cases.

VIII. Outcome: Evaluating the Response – Follow-up and Results

Report the actual outcome of the treatment ^1^, describe the clinician's assessment of the patient's progress ^9^, and include important follow-up diagnostic assessments ^9^. Assess adherence to and tolerance of the intervention, including any adverse events ^9^. Include the patient's prognosis, if known ^6^. This section provides the results of the treatment and the overall course of the patient's condition. By detailing how the patient responded to the treatment and their condition at follow-up, this section provides crucial information about the effectiveness and safety of the intervention.

IX. Discussion: Interpreting the Findings – Context and Significance

Begin by expanding on the introduction, highlighting why the case is noteworthy and the questions it addresses ^1^. Summarize and explain the key findings of the case ^10^. Compare the findings with previously reported cases and existing literature ^1^, explaining how the case is different or unique ^6^, and critically evaluate the cited references ^10^. Derive new knowledge and discuss its applicability in practice ^10^, drawing clinically meaningful conclusions ^10^. State the strengths and limitations of the case report's approach ^9^. Clarify how the case report informs practice or guidelines ^9^. Explain why the case report contributes to the medical literature and highlight any learning points ^6^. Discuss treatment strategies and outcomes in the context of existing hypotheses and literature findings ^7^. Mention similarities and differences between the findings and the literature, and how the case might impact future clinical practice ^7^. Consider how the case report might raise testable hypotheses ^9^. The discussion is the most critical section, where the authors interpret their findings in light of existing knowledge and emphasize the significance of the case. Simply presenting a case without placing it within the broader context of medical literature limits its value. The discussion section ^1^ requires authors to critically analyze their findings based on what is already known, explaining how their case confirms, contradicts, or expands upon existing knowledge. This intellectual engagement is key to transforming a case description into a valuable contribution to the medical field.

X. Conclusion: The Final Summary – Encapsulating Key Takeaways

Briefly orient the reader to the key points covered in the case report ^1^, restate the main conclusions of the case report ^9^, and provide a concise statement and explanation of the importance and relevance ^9^. Offer suggestions and recommendations for clinicians, teachers, or researchers, if applicable ^1^. The conclusion should be brief, ideally no more than one paragraph ^10^. The conclusion section provides a concise summary of the main message of the case report. This section should leave the reader with a clear understanding of the key learning points and the overall significance of the reported case.

XI. Patient Perspective (if applicable): The Patient's Voice – Insights and Experiences

Include the patient's perspective on the treatment or outcome, if relevant and with their consent ^2^. This can add a valuable dimension to the report, providing insights into the patient's experience of their illness and treatment.

XII. Patient Consent: Ethical Imperative – Ensuring Transparency

Informed consent is an ethical requirement for most human research ^1^. Written consent should be obtained from the patient (or parents/family when applicable) before writing the report ^1^, and a statement confirming that informed consent was obtained should be included ^7^. Maintain patient anonymity by not disclosing any identifying information ^1^. Exercise extreme caution when handling images ^1^. The CARE guidelines recommend obtaining informed consent whenever possible, along with the patient's perspective on the treatment/outcome ^2^. Obtaining and documenting the patient's informed consent is crucial for ethical publication. This section ensures that the patient is aware that their case will be reported and has given permission, and it highlights the measures taken to protect their privacy.

XIII. References: Citing Your Sources – Supporting Evidence

scifocus

List all references cited in the manuscript according to the target journal's specific format ^11^, and ensure the accuracy and completeness of all citations. Proper referencing is essential for academic integrity and allows readers to consult the cited literature. This section provides a list of all the sources consulted and cited in the case report, allowing readers to verify the information and explore the related literature in more depth.

XIV. Appendices (if applicable): Supplementary Material – Additional Information

Include any original data, images, or other materials that support the case but would interrupt the flow of the main text if included there ^11^. Ensure all appendices are clearly labeled and referenced in the main text. Appendices can provide additional context or evidence without disrupting the flow of the main report. This section allows for the inclusion of supplementary information, such as detailed imaging reports or raw data, that may be too lengthy or detailed to include in the main body but is still relevant to the case.

XV. Author Information: Acknowledging Contributions – Credentials and Affiliations

Include the full names and academic degrees of all authors ^3^, and provide the department and institutional affiliations for each author ^3^. Designate the corresponding author and provide their contact information ^9^, and list the details of each author's contributions ^6^. The first author is typically the person who conceived the study and did most of the work ^3^. The guarantor (usually the most senior member of the team) is often listed last ^6^. Disclose any sponsors or potential conflicts of interest ^3^. This section provides important information about the authors and their contributions to the case report. Clearly outlining the roles and affiliations of all authors ensures proper attribution and transparency. Disclosing any potential conflicts of interest is crucial for maintaining the credibility of the publication.

The following table summarizes the essential components of a medical case report:

Table 2: Essential Components of a Medical Case Report

Section Name	Main Content/Purpose	Relevant Snippets
Title	Clear, informative, and concise reflection of the content	^3^
Abstract	Brief summary of key aspects, including chief complaint, diagnosis, intervention, and outcome	^1^
Introduction	Provides background, significance, rationale, and relevant literature review	^1^
Case Presentation	Detailed description of patient demographics, chief complaint, history, and physical examination findings	^3^
Observations and Investigations	Details of pathological and other investigation results, diagnostic reasoning, and prognostic features	^1^
Diagnosis	Clear statement of the final diagnosis
Treatment	Description of intervention type, methods, duration, and rationale	^1^
Outcome	Reports the actual outcome of treatment, clinical assessment, follow-up, and prognosis	^1^
Discussion	Interprets findings, compares with literature, draws conclusions, and discusses significance	^1^
Conclusion	Summarizes key takeaways, restates main conclusions, and offers recommendations	^1^
Patient Perspective (if applicable)	Includes the patient's insights and experiences with their illness and treatment	^2^
Patient Consent	Confirmation of written informed consent and maintenance of patient anonymity	^1^
References	List of all cited sources	^11^
Appendices (if applicable)	Provides supplementary data, images, or other materials supporting the case	^11^
Author Information	Includes author names, credentials, affiliations, and contributions	^3^

Step 3: Polishing Your Work – Tips for Writing a High-Quality Case Report

Writing a compelling and informative case report requires careful consideration and refinement. Here are some tips to help you enhance the quality of your report:

Conduct a Thorough Background Search: Research the disease/pathology related to your case to contextualize it within existing literature ^6^.
Organize Information Logically and Chronologically: Present the case in a clear, step-by-step manner, following the patient's journey ^3^.
Use Clear and Precise Medical Terminology: Ensure accuracy in terminology and avoid jargon where possible, or explain it clearly.
Be Concise and Focused: Avoid unnecessary details and keep the report focused on the key learning points of the case ^10^.
Emphasize the Novelty: Clearly articulate what makes your case different or significant compared to previously published cases ^6^.
Include Relevant Tables and Figures: Use visual aids to enhance understanding and present complex data effectively ^9^.
Maintain Patient Privacy: Double-check for any potentially identifying information.
Obtain and Document Informed Consent: Ensure all ethical requirements are met.
Review and Edit Carefully: Proofread for grammar, spelling, and clarity. Ask colleagues to review your report and provide feedback ^6^. Consider using the CARE guidelines checklist ^2^.
Write the Abstract Last: This helps ensure the abstract accurately reflects the content of the completed report ^3^.

Step 4: Sharing Your Findings – Selecting a Journal and Completing Submission

Choosing the right journal is crucial for ensuring your case report reaches its target audience and has an impact. Here's how to select a journal and navigate the submission process:

Identify Potential Journals: Search PubMed, use journal finder tools (e.g., JANE, Wiley's Journal Finder, Elsevier's Journal Finder), look at journals from professional societies, and consider journals that have published similar case reports ^2^.
Review Journal-Specific Guidelines: Carefully read the target journal's 'Instructions for Authors' or 'Author Center' to understand their specific requirements for case reports, including formatting, word limits, referencing style, and any fees ^2^.
Ensure Ethical Policy Alignment: Verify the journal's requirements regarding informed consent, IRB approval (if needed), and disclosure of conflicts of interest ^2^. Note that case reports discussing a single patient often may not require IRB approval as they are not always considered research ^2^.
Prepare Your Manuscript: Format your case report according to the journal's specifications.
Write a Compelling Cover Letter: Introduce your case report and highlight its novelty and importance to the journal's readership ^9^.
Submit Your Manuscript: Follow the journal's online submission process.

Conclusion: Leaving Your Mark – Contributing to the Medical Literature

Medical case reports hold significant value in medical education, practice, and research. Scifocus can provide unique clinical insights that can advance our understanding of diseases and ultimately improve patient care. Writing a high-quality case report requires rigorous thinking, meticulous documentation, and a strong commitment to ethical principles. By sharing unique clinical experiences, healthcare professionals can make valuable contributions to the advancement of medical knowledge and the improvement of patient outcomes.

References

Guidelines to Writing a Clinical Case Report - PMC. Retrieved March 20, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC5686928/
Writing a Case Report. Retrieved March 20, 2025, from https://research.chm.msu.edu/students-residents/writing-a-case-report
How to Write a Case Report Abstract - Research Guides. Retrieved March 20, 2025, from https://guides.temple.edu/c.php?g=1320941&p=9717587
Structure of a Case Report - How to Write and Publish a Case ... Retrieved March 20, 2025, from https://guides.temple.edu/c.php?g=1336360&p=9845299
Case Report Example. Retrieved March 20, 2025, from https://www.csctr.org/UserFiles/file/CaseReportExample.pdf
Writing a Case Report in 10 Steps | The BMJ. Retrieved March 20, 2025, from https://www.bmj.com/content/350/bmj.h2693
How to Write a Case Report - Wiley. Retrieved March 20, 2025, from https://www.wiley.com/en-us/network/publishing/research-publishing/forward-series/how-to-write-a-case-report
Case Reports - Guidelines | Article Preparation for Submission | F1000Research. Retrieved March 20, 2025, from https://f1000research.com/for-authors/article-guidelines/case-reports
Guideline on Writing a Case Report - PMC - PubMed Central. Retrieved March 20, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC6476221/
Tips for Writing a Case Report for the Novice Author - PMC. Retrieved March 20, 2025, from https://pmc.ncbi.nlm.nih.gov/articles/PMC4175810/
Case Study - Student Academic Success - Monash University. Retrieved March 20, 2025, from https://www.monash.edu/student-academic-success/excel-at-writing/how-to-write/case-study