Ten Steps to Writing an Effective Case Report (Part 2)

In our previous article, we discussed the first 5 steps in writing an effective Case Report. Here, let us look at the remaining 5 steps.

Step 6: Deciding the Contents of the Case Report

Summarize the information that you have gathered:

  • A brief history and important and relevant positive and negative findings with details of investigations
  • Treatment
  • The condition of the patient after treatment


A common form of presentation is to divide the content into a textbook style of presentation without the headings—history, examination, investigation, treatment, and outcome in separate paragraphs.

Step 7: Writing the Introduction

Follow the rule of brevity!

State the issue and its significance. You can also cite some articles that have already referred to this problem.

Tip 1!

Do not forget to mention how rare the condition is.

Step 8: Patient Data and Case Description

Since a Case Report is usually about a single or a group of patients, this section plays a very important role. Patient consent is a very crucial point and should compulsorily be mentioned. Obtaining consent from the patient is not only a good medical practice but also mandatory for most journals, such as BMJ (which has its own consent form on the journal’s website).

The case is usually described in chronological order.

Tip 2!

Provide the results of the relevant examinations and laboratory tests, usually only those with positive results.

Step 9: Discussion and Conclusion

These sections are written differently from those in other types of research articles.

Proceed point-by-point when writing the Discussion:

  • First, explain the objective of reporting the case.
  • Describe what others have written before about the condition or any related feature.


Be generous in quoting literature but do not include unnecessary details.

  • The most important point to note is that your reviewers want proof of the rarity of the condition and the scientific explanations for it.


Answer these questions in the Discussion section:

  • Describe the cause of the condition or why a particular procedure or feature was chosen.
  • How did it influence the outcome?
  • How does it differ from usual and what are your recommendations?
  • Are there any lessons to be learnt?

The Conclusion is not always necessary in a Case Report, but if it is, summarize in a few sentences.

Step 10: References and Other Formatting

The reference section is extremely important. Adhere to the style (Vancouver, Harvard, etc.) that your journal requires. Also, as mentioned previously, the formatting will affect the acceptance of your report to a great extent. Therefore, take care of all formatting instructions related to margins, spacing, figure numbering, and the type of English.

The Stages in Writing a Case Report Can be Summarized as Follows:


Content should be brief and less than 3 paragraphs:

  • State the purpose of the case report
  • Provide background information and pertinent definitions
  • Introduce the patient’s case

Patient’s Case Presentation

Ensure that the patient’s case presentation provides enough detail for the reader to establish the case’s validity:

  • Patient demographics (age, sex, height, weight, etc.)—avoid patient identifiers (date of birth, initials)
  • Patient’s complaints
  • Patient’s present illness and medical/family/social/medication history before admission
  • Each drug’s name, strength, dosage form, route, and dates of administration
  • The completed diagnostic procedures that are pertinent and support the case and their salient results.
  • Photographs of histopathology, roentgenograms, electrocardiograms, skin manifestations, or anatomy
  • Patient consent and adherence to institutional guidelines


Justify the uniqueness of the case in this section:

  • Compare and contrast the nuances of the case report with the literature review
  • List the limitations of the case report and describe their relevance
  • Confirm the accuracy of the descriptive patient case report
  • Summarize the salient features of the case report
  • Draw recommendations and conclusions


This section should be brief and not exceed one paragraph:

  • Provide a justified conclusion
  • Provide evidence-based recommendations
  • List opportunities for research


We hope you find the information valuable while writing your Case Report. Comment below and let us know your thoughts.

  1. dr. ankita says

    Thanks a ton!!!!!!!!!!!!!

  2. Mahjabeen says

    thanks a-lot… can u please refer me the journals that published case report?

    1. Enago Academy says

      Dear Mahjabeen,

      Thank you for your positive comment.

      We are glad to know that you found our resources useful. Your feedback is very valuable to us.

      You can check some journals that publish case reports here. In addition, you can also find the most appropriate journal for your manuscript using the Enago Open Access Journal Finder.

  3. Sampath says

    Highly comprehensive letter , thank you verymuch

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