Writing Your First Case Report

Case reports have been described as being inferior and the weakest level of clinical evidence. While it is true that a journal case report cannot supersede the power of a clinical trial for the evidence based data it generates, the case report still has an important role to play in the medical literature. Case reports serve the function of proposing new hypotheses and sharing clinical observations that can then become the focus of a larger scientific study. Writing a report about a rare disease may be the primary way to publicize it, as small patient numbers would make it unlikely that such a disease would ever be part of a clinical trial or other research investigation. Learning how to write a case report is a skill that early stage researchers may need to acquire. The format of the case report is specific to the requirements of the target journal that, so it is important that the authors first consult the chosen journal’s instructions for authors before starting to draft the article.

The report of the first case of AIDS and Parkinson’s disease were both published as case reports. This obviously raised awareness of these illnesses in the medical and scientific communities which has spawned many research endeavors that seek to treat and cure these diseases. Case reports initially started as more anecdotal discussions between physicians but have since been formalized into a more scholarly format.

A Guide to Writing Case Reports

One of the best ways to tackle any piece of scholarly work is to seek to understand its purpose. A case report is most useful when it

  • Describes a new disease
  • Describes rare manifestations of a known illness
  • Clarifies the mechanism of an illness
  • Outlines adverse or beneficial side effects of a treatment course
  • Contributes to medical education.

Related: Finished drafting your case report? Check these journal selection guidelines now!

Before writing a case report, it might be a good idea to check if the case fits these criteria:

  • Obtaining informed consent to write the case report is critical. It is important that the patient information is protected and patient confidentiality is not violated. Some journals follow a case report format that includes the patient’s perspective. If authors had obtained informed consent from the patients at the time of commencement of the study, the patients might agree to contribute their perspective to the case report.
  • Once the patient’s consent is obtained, authors need to decide on a journal to submit the case report to. Authors must ensure to choose a journal whose target audience is likely to be interested in the case being reported. Once the decision is made, authors must read the journal’s guidelines to ensure that the case report format meets the specified instructions. Authors should also refer to the more recent case reports published in the journal. This will help authors get an idea about the style that is expected and the types of case reports the journal tends to publish. Once that has been done, the next logical step is to focus on drafting the case report sections.

Case Report Format

The format for the case report will be dictated by the target journal. A typical case report includes the:

  1. Title
  2. Abstract
  3. Introduction
  4. Case description
  5. Discussion
  6. Conclusion and a Patient’s Perspective (in some cases)

The title and the abstract are two key components of any academic article. These sections are both freely available and readers typically go through the abstract to determine if they want to read the full case report.


The title should be:

  • Accurate
  • Concise
  • Relevant

An interesting or catchy title might help attract readers to the study. Authors may choose to write the title after the rest of the report to ensure it reflects the tone of the predominant issue in the case report.


The abstract is usually less than 300 words and summarizes the contents of the case report.

The title and abstract are used to index your case report in order to facilitate literature search. It is advisable to refer to the journal’s instructions to structure the abstract accordingly.


While some journals require an introduction, other journals prefer that the case description directly follows the abstract. The introduction should provide the required context to the readers to understand why the authors chose to publish the case report. However, authors must ensure that it is not an extensive literature review.

Case Description

The case description should proceed chronologically and provide sufficient details to the readers to understand how the authors arrived at the diagnosis and why they chose to administer the treatments. In this section, it is essential to provide only the information needed to properly describe the case. Authors must exclude any data that is not essential to understanding the diagnosis and treatment.


In the discussion section, authors should justify their opinions and make suitable recommendations. Authors should assess the particular case for accuracy and novelty. Extensive literature review should be avoided.

In most cases, journals limit the references associated with a case report to no more than 15 papers.

Things to Remember

The most important thing to bear in mind when it comes to how to write a case report is the purpose of writing one – which is to raise awareness about any unusual cases seen during the course of one’s medical practice. It is important to adhere to the case report format prescribed by the journal. It is also important to obtain required patient consent and to follow the guidelines specified by the respective institutional review board.

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