How do you write a case report for a medical journal?

Start by identifying the case's clinical significance, then prepare the title, abstract, introduction, case presentation, discussion, conclusion or learning points, and references. Follow the target journal's instructions and address consent, confidentiality, and applicable ethical requirements.

What is the standard structure of a medical case report?

A typical medical case report includes a title, abstract, introduction, case presentation, discussion, conclusion or learning points, and references. Depending on the journal, it may also include a timeline, patient perspective, and declarations.

What are the CARE guidelines for case reports?

The CARE guidelines provide a framework for transparent case-report writing. They cover essential information such as patient details, clinical findings, diagnostic assessment, interventions, follow-up, discussion, and informed consent.

Is patient consent required for publishing a medical case report?

Patient consent for publication is commonly required, particularly when clinical details or images could identify the patient. Authors should follow the journal's consent policy, institutional procedures, and applicable ethical requirements.

How long should a medical case report be?

The required length varies by journal and article type. Authors should check the target journal's word limit, abstract requirements, figure limits, and reference guidelines before preparing the final manuscript.

What makes a medical case report suitable for publication?

A publishable case report should offer a meaningful clinical lesson, an unusual presentation, a diagnostic challenge, an informative complication, or another relevant observation. It should provide adequate clinical detail and avoid conclusions unsupported by the case.

Can a case report be published without ethics committee approval?

Requirements vary by institution, jurisdiction, and journal. Some institutions exempt individual case reports from formal ethics review, while others require review or a documented exemption. Authors should verify the applicable requirements rather than assume approval is unnecessary.

How can authors improve the chances of case report acceptance?

Choose a suitable journal, establish the case's clinical relevance, follow the CARE guidelines, provide a clear clinical timeline, support the discussion with relevant literature, obtain required consent, and ensure that the conclusions are appropriately cautious.

How to Write a Case Report for a Medical Journal

A medical case report describes an unusual, educational, or clinically significant patient presentation that can contribute to medical knowledge. It may highlight a rare disease, an unexpected adverse drug reaction, an atypical clinical presentation, an uncommon complication, a diagnostic challenge, or a treatment outcome that offers useful lessons for healthcare professionals.

Although case reports generally provide a lower level of evidence for determining treatment effectiveness than controlled studies, they can play an important role in identifying emerging clinical patterns, generating research hypotheses, and alerting clinicians to previously underrecognised conditions.

Writing a case report for a medical journal requires more than describing a patient's symptoms and treatment. Authors must present a clear clinical narrative, explain why the case matters, protect patient confidentiality, obtain appropriate consent, and follow the target journal's submission requirements.

This guide explains how to write a medical case report, organise its sections, select an appropriate journal, meet ethical requirements, and prepare the manuscript for peer review. For related guidance on manuscript preparation, see How to Write the Materials and Methods Section of a Medical Research Paper.

What Is a Medical Case Report?

A medical case report is a detailed description of one patient's clinical experience or, in some formats, a small number of clinically related cases. It documents relevant information about the presentation, diagnostic process, treatment, follow-up, and clinical lessons.

Case reports can be useful across specialties, including internal medicine, surgery, cardiology, oncology, neurology, dermatology, paediatrics, infectious diseases, radiology, and pharmacology.

Common reasons to consider writing a case report include:

A rare disease or an unusual presentation of a familiar condition
An unexpected complication following a procedure or treatment
A suspected adverse drug reaction
An important diagnostic dilemma
An unusual association between clinical findings
A novel or particularly informative treatment response
A previously unreported clinical observation that warrants further investigation

However, rarity alone does not guarantee publication. A strong report explains why the case is educational, clinically relevant, or capable of informing further investigation.

Why Do Medical Journals Publish Case Reports?

Case reports can provide early observations that may be difficult to capture in large clinical studies, particularly when a condition is rare or an event is unexpected.

1. Identifying unusual clinical presentations

A case report may alert clinicians to a disease presenting with symptoms that differ from the typical pattern. This can encourage earlier recognition and consideration of appropriate differential diagnoses.

2. Highlighting potential adverse events

Reports of suspected adverse reactions or unexpected complications can draw attention to possible safety concerns. A single case cannot usually establish causation, but it may justify further investigation.

3. Sharing diagnostic lessons

A detailed account of a diagnostic challenge can explain how clinical history, examination, laboratory testing, imaging, and specialist consultation contributed to the final diagnosis.

4. Generating research hypotheses

Unusual observations may raise questions for future laboratory studies, observational research, clinical trials, or systematic reviews.

5. Supporting medical education

Case reports can connect clinical reasoning with real-world practice. They are particularly useful when the diagnostic pathway, management decisions, or lessons are explained clearly.

Authors should avoid claiming that one case establishes a general treatment recommendation. The report should distinguish what was observed in the patient from what can reasonably be inferred for other patients.

Before Writing: Is the Case Suitable for Publication?

Before preparing the manuscript, determine whether the case offers a meaningful contribution and whether the necessary ethical and clinical information is available.

Assess the educational or scientific value

Ask the following questions:

Does the case illustrate a clinically important diagnostic or management challenge?
Is the presentation unusual, or does it offer a useful lesson even if the condition itself is common?
Does it add information beyond what has already been reported?
Can the clinical course be documented adequately?
Are the conclusions supported by the available evidence?

A focused literature search can help establish whether similar cases have been published. Search relevant medical databases and use terms describing the diagnosis, presentation, complication, intervention, and other distinguishing features.

Choose the appropriate report type

Some journals accept a single-patient case report, while others prioritise case series, clinical images, brief communications, or educational case challenges. These formats have different structural requirements.

Read the target journal's author instructions before drafting. Do not assume that every journal accepts conventional case reports.

Standard Structure of a Medical Case Report

The exact structure varies by journal and specialty. A common format includes the title, abstract, keywords if requested, introduction, case presentation, discussion, conclusion or learning points, references, and relevant declarations.

The CARE guidelines (CAse REport guidelines) provide a widely used framework for transparent reporting of clinical case reports. Authors should consult the official CARE checklist and the journal's requirements when preparing a manuscript.

1. Title

The title should accurately describe the main clinical feature and make the report's relevance clear. It should be concise, informative, and consistent with the journal's instructions.

A useful title may identify the diagnosis, unusual presentation, complication, or central clinical lesson.

For example: An Unusual Presentation of [Condition]: A Case Report

This is an illustrative format rather than a suggested title for a real patient. Authors should use precise clinical terminology and avoid sensational language.

The phrase "case report" should be included when required by the journal or applicable reporting guidance. Avoid implying that a case is the first ever reported unless a sufficiently comprehensive literature search supports that claim.

2. Abstract

The abstract summarises the case and explains why readers should pay attention to it. Some journals require a structured abstract with headings; others request a single paragraph.

Depending on the journal's instructions, include:

Background: The clinical issue or reason the case is noteworthy
Case presentation: The patient's relevant presentation, investigations, diagnosis, treatment, and outcome
Conclusion: The principal clinical lesson or implication

The abstract should be consistent with the full text and avoid information that is not supported by the case details.

For example, if the report describes a suspected adverse drug reaction, the abstract should not present the drug as definitively responsible unless the evidence supports that conclusion.

Observe the journal's word limit and any restrictions on abbreviations, references, or headings in the abstract.

3. Introduction

The introduction explains the clinical context and establishes why the case deserves publication. It is usually brief and focused.

A strong introduction should:

Introduce the condition, clinical problem, or complication
Summarise the relevant background evidence
Identify the unusual or educational feature
State the purpose or principal lesson of the report

Avoid turning the introduction into a lengthy textbook overview. Include only the background necessary to understand the case and its relevance.

The introduction should lead naturally into the case presentation and make the report's contribution clear without exaggerating novelty.

4. Case Presentation

The case presentation is the central section of the manuscript. It should provide an accurate, chronological account of the patient's clinical course.

Only information relevant to understanding the diagnosis, treatment, and clinical lesson should be included.

Patient information and presenting complaint

Describe the patient's relevant demographic information and the main reason for seeking care. Include the presenting symptoms, their duration, important medical history, relevant medication use, and pertinent family or social history where appropriate.

Use only the demographic details needed for clinical interpretation. Avoid unnecessary identifying information.

Clinical findings

Describe important findings from the physical examination, vital signs, and specialist assessments. Explain the findings that influenced the differential diagnosis or subsequent management.

Do not include long lists of normal findings unless they are clinically relevant.

Diagnostic assessment

Explain how the diagnosis was established. Depending on the case, this may include:

Laboratory results
Radiological or other imaging findings
Histopathology or microbiology
Electrocardiography or other investigations
Specialist assessments
Differential diagnoses and the reasoning used to evaluate them

Report important results accurately, including relevant units and reference ranges where appropriate. If an investigation was inconclusive or a diagnostic possibility could not be excluded, state this clearly.

Treatment and intervention

Describe the treatment or intervention in sufficient detail for readers to understand what was done and why.

Depending on the case, include relevant drug names, doses, routes, duration, procedures, supportive care, and changes to the treatment plan. Explain the clinical rationale for major decisions when it helps readers follow the management process.

Avoid implying that a particular intervention caused improvement solely because the patient improved afterward. Other treatments, natural disease progression, and confounding factors may contribute to the outcome.

Follow-up and outcomes

Report the patient's subsequent clinical course, response to treatment, complications, recurrence, and follow-up findings where available.

If follow-up was limited, state this as a limitation. If the patient was lost to follow-up, do not imply that the final outcome is known.

A clear timeline can make complex clinical events easier to understand, particularly when several investigations or interventions occurred over a short period.

5. Timeline

A timeline is useful when the sequence of events is central to understanding the case. It may show symptom onset, clinical assessment, diagnostic testing, treatment changes, and follow-up.

A concise table can help readers interpret the chronology.

Time point: Initial presentation. Clinical event: Symptoms and relevant examination findings.

Time point: Diagnostic assessment. Clinical event: Key tests and differential diagnoses.

Time point: Diagnosis. Clinical event: Final or working diagnosis and supporting evidence.

Time point: Treatment. Clinical event: Intervention and relevant treatment changes.

Time point: Follow-up. Clinical event: Response, complications, and subsequent outcome.

This is a generic template. Authors should replace the entries with accurate, appropriately de-identified details from the actual case.

6. Discussion

The discussion explains what the case contributes to existing clinical knowledge. It should interpret the findings, compare them with relevant literature, and identify the implications and limitations.

A well-organised discussion often addresses four areas.

Principal finding: Begin by explaining the main clinical observation or lesson.

Comparison with previous literature: Discuss relevant published cases, reviews, or clinical guidance. Explain how the current case resembles or differs from previously reported presentations.

Clinical implications: Describe what clinicians may learn from the case, such as a differential diagnosis to consider, a potential complication to recognise, or a question that requires further study.

Limitations: Identify uncertainty, incomplete investigations, limited follow-up, alternative explanations, or other factors that restrict the conclusions.

Avoid using the discussion to repeat the entire case presentation. Focus on interpretation rather than simply restating the patient's history.

Interpreting unusual findings carefully

If the patient improved after receiving a treatment, the report may describe the observed association. However, the author should consider whether other factors could explain the improvement.

Similarly, a suspected adverse drug reaction should be described in terms of the available clinical evidence and the level of certainty. The discussion should not convert a temporal association into a definitive causal claim without sufficient support.

7. Conclusion or Learning Points

Some journals request a separate conclusion, while others prefer brief learning points or a "take-home message."

The final section should summarise the most important clinical lesson in a few clear sentences. It should follow from the case details and discussion.

For example, the conclusion might emphasise the importance of considering a particular differential diagnosis when a defined combination of findings is present. The actual lesson should be specific to the case rather than a broad claim based on a single observation.

Do not introduce new results or make treatment recommendations that the case cannot support.

8. Patient Perspective

The CARE reporting framework includes a patient perspective where appropriate and available. Some journals may request the patient's account of the illness, treatment, or recovery.

If included, the perspective should be obtained with appropriate permission and handled in a way that protects privacy. It should reflect the patient's own experience rather than being presented as a clinician-written statement attributed to the patient.

If a journal does not require this section or a patient perspective cannot appropriately be obtained, follow its instructions and report any relevant limitations honestly.

9. References

References support the clinical context and the interpretation of the case. They should be selected for relevance and reliability rather than quantity.

Useful sources may include peer-reviewed case reports, clinical studies, systematic reviews, specialty guidelines, and authoritative drug-safety information.

When citing previous case reports, explain how they relate to the current case. Do not suggest that a finding is unprecedented simply because a quick search did not identify a matching publication.

Follow the journal's reference style, including author names, article titles, journal abbreviations, publication details, and digital object identifiers where required.

Ethical and Patient-Confidentiality Requirements

Ethical reporting is essential when a manuscript describes an identifiable or potentially identifiable patient.

Informed consent for publication

Obtain the patient's informed consent for publication when required by the journal and applicable ethical standards. Consent for treatment is not automatically equivalent to consent for publication.

If the patient is a child or cannot provide consent, the appropriate legally authorised representative or guardian may need to provide permission, subject to applicable requirements. Additional safeguards may apply to vulnerable patients.

Authors should use the journal's approved consent form when one is provided and retain documentation according to institutional policy. Do not upload consent documents containing identifiable information unless specifically required through an appropriate secure process.

Patient anonymity

Remove unnecessary identifying details from the manuscript, images, scans, and supplementary files. Names, initials, hospital registration numbers, exact dates, and other identifying details should not be included unless there is a legitimate, permitted reason and the journal's procedures are followed.

Removing a name alone does not guarantee anonymity. A combination of rare clinical details, dates, location, and images may identify a patient.

Authors should not alter clinically important information in a way that misrepresents the case. If dates or other details are generalised to protect privacy, ensure the changes do not distort the clinical chronology or interpretation.

Ethics committee or institutional review

Whether ethics committee approval or an exemption is required depends on the institution, jurisdiction, type of report, and journal policy. Some institutions do not require formal ethics review for a single case report, while others have specific procedures.

Authors should verify the applicable institutional and journal requirements rather than assuming that every case report is automatically exempt.

Report approval or exemption accurately when required. Never claim that approval was obtained if it was not.

Conflicts of interest and funding

Disclose relevant financial and non-financial competing interests. If the case report received funding or other material support, provide the information requested by the journal.

These declarations should be accurate even when the authors believe that the support did not affect the report.

Using the CARE Guidelines for Case Reports

The CARE guidelines provide a structured approach to reporting case information transparently. Their checklist covers important elements such as the title, abstract, patient information, clinical findings, timeline, diagnostic assessment, intervention, follow-up, discussion, patient perspective, and informed consent.

The checklist can help authors identify missing information before submission. It does not replace clinical judgement, ethical requirements, or the journal's own instructions.

Before submitting a case report, consult the official CARE guidelines and checklist. Check the version and any additional reporting requirements relevant to the target journal. For related guidance, see STROBE Checklist for Observational Studies: Medical Research Guide.

Tables, Images, and Supplementary Materials

Clinical images, diagnostic scans, pathology slides, timelines, and tables can strengthen a case report when they provide information that is difficult to communicate in text alone.

Clinical images

Images should be relevant, clear, and appropriately labelled. Captions should explain what is shown and identify important findings without overstating their significance.

Before submission, confirm that the image quality meets the journal's technical requirements and that patient consent covers publication of relevant images where required.

Remove identifiers embedded in image files, including labels, names, medical record numbers, and dates that could reveal identity.

Tables and figures

Use tables to organise complex laboratory findings, medication changes, or chronological information. Figures should clarify the clinical message rather than repeat the text.

Each table and figure should be cited in the manuscript and supplied in the format requested by the journal. Ensure that all abbreviations, symbols, units, and reference ranges are explained where necessary.

Supplementary materials

Some journals permit additional imaging, detailed timelines, or other supporting documents as supplementary files. Include these only when they improve the report and comply with privacy, consent, and formatting requirements.

How to Select the Right Medical Journal

Choosing an appropriate journal can improve the relevance of the submission and help authors avoid unsuitable publication venues.

Check the journal's scope

Look for journals that publish case reports in the relevant medical specialty. Review recent articles to determine whether the journal accepts cases similar in topic, complexity, and format.

Review author instructions

Confirm the required manuscript structure, abstract format, word count, figure limits, reference style, consent documentation, and any reporting checklist requirements.

Examine publication practices

Review the journal's editorial board, peer-review process, publication fees, indexing claims, publication ethics policies, and publisher information.

Be cautious of journals that guarantee acceptance, promise implausibly rapid peer review, or make misleading claims about indexing.

Consider fees and access

Check whether the journal charges a submission fee, publication fee, or article processing charge. Confirm the terms before submission, especially if funding is limited.

Open-access publication may increase accessibility, but the journal's legitimacy and suitability should be assessed independently of its access model.

Common Reasons Medical Case Reports Are Rejected

A case report may be rejected even when the clinical event is unusual. Common reasons include:

Limited educational value: The report describes a case without explaining what readers can learn from it
Weak literature review: The authors do not establish how the case relates to existing knowledge
Incomplete clinical information: Important diagnostic findings, treatment details, or follow-up data are missing
Overstated conclusions: The discussion makes causal claims or treatment recommendations unsupported by a single case
Ethical documentation problems: Consent or institutional requirements have not been addressed adequately
Poor organisation: The timeline is unclear, and the discussion repeats the case narrative
Journal mismatch: The selected journal does not accept case reports or does not publish the relevant subject area
Formatting errors: The manuscript does not comply with the journal's submission requirements

A final review focused on clinical accuracy, ethical compliance, relevance, and reporting completeness can help reduce avoidable problems.

Final Checklist Before Submitting a Case Report

Before submitting the manuscript, confirm that:

The title clearly identifies the clinical focus
The abstract accurately reflects the report
The case presentation follows a clear chronological sequence
Diagnostic findings and treatment details are reported accurately
The discussion explains the case's contribution and limitations
The conclusions are proportionate to the evidence
Relevant literature has been reviewed and cited appropriately
Patient consent and confidentiality requirements have been addressed
Ethics approval or exemption has been verified where applicable
Conflicts of interest and funding are disclosed
The CARE checklist and any journal-specific documents are completed as required
Figures, tables, captions, and references meet the journal's specifications

A medical case report can make a valuable contribution to clinical knowledge when it is well documented, ethically prepared, and clearly written. The strongest reports combine a compelling clinical narrative with a careful discussion of context, limitations, and implications.

Authors should remember that a single case cannot establish treatment effectiveness or prove causation. Its value lies in generating hypotheses, sharing diagnostic lessons, and alerting clinicians to unusual presentations or potential safety concerns.

By following a structured format, addressing ethical requirements, and consulting the CARE guidelines, researchers can improve the quality and publication readiness of their case reports. For those considering doctoral research in this area, Top 10 Pharmaceutical Research Topics for PhD offers guidance on selecting impactful research directions.