Key Takeaways:
- A case report is a detailed, peer-reviewed account of a single patient’s unusual symptoms, diagnosis, treatment, or outcome that gives other clinicians a genuinely new lesson.
- Most journals expect a title, abstract, introduction, case presentation, discussion, and conclusion, though exact section names and word limits vary by journal.
- The strongest case reports are chosen for novelty and teaching value: an unexpected presentation, a diagnostic pitfall, a rare complication, or a management approach that departs from routine practice.
Glossary of Key Terms
The table below defines terms used throughout this article.
| Term | Definition |
| Case report | A short, structured, peer-reviewed write-up of 1 patient’s unusual presentation, diagnosis, treatment, or outcome. |
| Case series | A report describing 3 or more patients who share a similar condition, exposure, or outcome. |
| CARE checklist | A 13-item reporting guideline that authors use to ensure a case report is complete and transparent. |
| Abstract | A short summary, usually 150 to 250 words, that appears before the main text of the report. |
| Case presentation | The section that describes the patient’s history, examination findings, investigations, and clinical course. |
| De-identification | The process of removing names, dates, and other details that could identify a patient before sharing data. |
| Informed consent | Written permission from a patient, or their legal guardian, allowing their case to be published. |
| IRB | Institutional Review Board: the ethics committee that reviews research and publication involving human subjects. |
| Novelty | The quality of being new or unexpected; the main reason journals accept a case report for publication. |
| Teaching point | The specific, explicit lesson a reader should take away from the case. |
| Peer review | The process by which independent experts assess a manuscript’s quality before a journal accepts it. |
What Is a Case Report?
A case report is a detailed scientific description of 1 patient’s unusual symptoms, diagnosis, treatment, or outcome, written to teach other clinicians something new.
Unlike a full research article, a case report does not test a hypothesis across a large sample. It instead documents a single, real clinical encounter in enough depth that another clinician can learn from it and apply the lesson to their own practice.
Case reports are common in medicine, but the same format is used in law, business, nursing, dentistry, veterinary science, and social work, wherever a single instance illustrates a broader problem or principle.
Why Do Case Reports Matter?
Case reports matter because they are often the first place a rare disease, an unusual drug reaction, or a diagnostic pitfall gets documented in the medical literature.
They generate hypotheses that larger studies later test, alert clinicians to patterns they may not have seen before, and preserve clinical knowledge that would otherwise exist only as word-of-mouth experience within 1 department.
- Early warning: many drug safety signals and new syndromes were first flagged through case reports.
- Education: trainees and specialists learn diagnostic reasoning from real, worked examples.
- Hypothesis generation: a single striking case can prompt a formal cohort study or clinical trial.
What Are the Main Types of Case Reports?
The main types are the single case report, the case series, and shorter formats such as brief reports and letters, each with its own scope and word limit.
- Single case report: focuses on 1 patient and is the most common format.
- Case series: groups 3 or more related patients to show a pattern across cases.
- Brief report or letter: a condensed format, often 500 to 800 words, for a straightforward observation.
- Teaching case: structured around a diagnostic or management lesson for trainees.
- CARE-guided case report: follows the CARE checklist item by item, often required by clinical journals.
How Do You Find the Right Case to Report?
The right case is one that teaches an experienced clinician something they did not already know, not simply a case that was memorable or emotionally striking to the treating team.
Journals reject far more case reports for weak case selection than for weak writing. Picking the case carefully, before a single sentence is drafted, is the single highest-leverage step in the entire process.
What Makes a Case Worth Publishing?
A case is worth publishing when it offers a clear, defensible reason to exist: something a reader could not learn from a textbook or a routine chart review.
Ask whether the case changes how a clinician would think or act the next time they see something similar. If the answer is no, the case, however interesting to treat, is unlikely to be accepted.
Common Sources of a Publishable Case
- An unexpected or atypical presentation of a common disease.
- A common presentation caused by a rare or overlooked disease.
- An unusual, unreported, or serious adverse reaction to a drug or device.
- A diagnostic pitfall: a case that was, or could easily have been, misdiagnosed.
- A rare complication of a standard treatment or procedure.
- A management approach that departs from the usual treatment pathway, with a clear rationale.
- An unusual combination of comorbidities that changed diagnosis or treatment.
How Can Medical Students Identify a Publishable Case?
Medical students can identify a publishable case by paying attention during ward rounds and clinics to any patient whose presentation, diagnosis, or treatment surprised the whole team, not just the student.
Watch for these signals in real time
- A senior clinician says something like “I have not seen this before” or “this is unusual.”
- The working diagnosis changed more than once before the team settled on the final answer.
- A test result did not match what the clinical picture predicted.
- The patient did not respond to the standard first-line treatment.
- A common drug caused an unexpected or serious side effect.
If 1 or more of these happens, that is worth writing down immediately, including the date, the ward, and the attending’s name, so the case can be tracked down later for formal write-up.
Use a simple screening question
Before committing time to a case, a student should ask 1 question: “If I told this story to a resident in this specialty, would they learn something new?” If the honest answer is no, the case is probably not publishable, however interesting it was to witness in person.
Talk to a supervising physician early
Students should not select and write up a case alone. A resident or attending can confirm whether the case is genuinely novel or just novel to the student because of limited clinical experience. This step also opens the door to co-authorship and mentorship, and it settles consent and ethics questions early rather than after the draft is finished.
Check the literature before investing time
A quick search of recent case reports on the same topic prevents wasted effort. If 3 or more similar cases were published in the last 2 to 3 years, the case may need a new angle, such as a different complication or an unusual management decision, to stand out.
Good starting points for students
- Morning report or grand rounds cases flagged as unusual.
- Elective or away rotations in a subspecialty, where rare presentations are more common.
- Cases the primary team explicitly asks a student to help document.
Students hold 1 advantage here: they often see cases with fresh eyes, before pattern recognition makes an unusual presentation feel routine. That fresh perspective is frequently what makes the difference between a forgettable case and a genuinely useful one.
A Quick Test Before You Commit to a Case
Before drafting, run the case past 4 short questions. If a case fails more than 1 of these, reconsider whether it is the right case to write up.
- Does the case have a single, clear teaching point that can be stated in 1 sentence?
- Is that teaching point something a specialist in the field does not already know?
- Can every claim in the case be supported by the chart, imaging, or laboratory data?
- Has the patient, or their guardian, agreed in writing to publication?
Avoid 2 common traps here: choosing a case simply because it was rare to see in person, and choosing a case before checking whether similar cases have already been widely published.
The Case Report Writing Process
Writing a case report happens in 2 broad phases: a pre-writing phase that structures your thinking before a single sentence is drafted, and a writing phase that turns that structure into a finished manuscript. Skipping the pre-writing phase is one of the most common reasons a first draft feels disorganized and has to be substantially rewritten.
Pre-Writing Phase
This phase is about gathering and organizing everything the manuscript will need, so the actual writing becomes a matter of assembly rather than discovery.
- Select a case based on a clear research question, using the novelty criteria described earlier in this article.
- Develop a theoretical framework: decide whether this case supports, challenges, or extends existing knowledge, since this framing shapes the entire discussion section.
- Collect all pertinent data from the chart, imaging, laboratory results, medication records, and, where relevant, interviews with the patient or family.
- Build a timeline of events, from first presentation through to final outcome, since timeline errors are one of the most common reasons reviewers flag internal inconsistencies.
- Analyze the case to identify key facts, root causes, and the specific lesson for readers, stating that lesson in 1 sentence before you begin drafting.
- Confirm informed consent in writing, and check whether your institution requires ethics or IRB sign-off, or a formal exemption, before you proceed.
- Search the recent literature for similar cases, so you can position your case against what has already been published.
Writing Phase
Once the groundwork is in place, the writing phase follows the standard structure that most journals expect, though section names can vary slightly.
- Introduction: state the key clinical problem, provide concise background, and make clear early on why this case matters.
- Case description: describe the patient’s history, examination findings, investigations, and clinical course in enough detail for another clinician to follow the reasoning.
- Outcomes: present what happened as a result of the intervention or management chosen, including any follow-up data available.
- Discussion and conclusion: explain the implications of the case, compare it against existing literature, acknowledge strengths and limitations, and restate the teaching point clearly.
A Note on Drafting Order
Many authors assume a case report must be written from the title down to the conclusion, in order. In practice, it is often easier to draft the case description first, since it is the most factual and least interpretive section, then write the discussion once the facts are settled, and finally write the introduction and title last, once you know exactly what story the case is telling. Writing the introduction last also helps ensure the stated reason for publication actually matches the case that follows, rather than a reason imagined before the data were fully reviewed.
Standard Case Report Format
There is no single, universally required format, but most journals expect the same core sections, summarized in the table below.
| Section | What It Should Contain |
| Title | A clear, jargon-free description of the case, without unnecessary abbreviations. |
| Abstract | A 150 to 250 word summary of the case and its significance, unstructured or structured. |
| Introduction | Background, the clinical problem, and why this case is worth reading. |
| Case presentation | Patient history, examination, investigations, diagnosis, and treatment given. |
| Discussion | How the case fits, or does not fit, existing literature, and what it teaches. |
| Conclusion | A short, explicit statement of the take-home message for readers. |
| References | Citations supporting the discussion; many journals cap the reference count. |
| Figures and tables | Timelines, imaging, and laboratory summaries that clarify the case. |
How do I choose keywords for a case report?
Choose 3 to 6 keywords that reflect the condition, the unusual feature, and the specialty involved, since these terms determine how easily other clinicians find your case in a database search. Include the specific diagnosis, for example “Lyme carditis” rather than just “cardiology,” plus terms describing the novel element, such as “atrioventricular block” or “reversible.” Many journals ask authors to use Medical Subject Headings, or MeSH terms, from PubMed’s official list rather than free-text phrases. Avoid overly broad terms like “case report” alone, since they add little value for search purposes.
Sample Case Report
Here’s a sample case report structured as a table, using a cardiology example. Ellipses indicate where fuller detail would normally appear in a real submission.
| Section | Sample Content |
| Title | Complete Heart Block Following Low-Dose Ivabradine in a Patient With Undiagnosed Lyme Carditis |
| Abstract | A 34-year-old male presented with dizziness and bradycardia… ECG showed complete heart block… Lyme serology confirmed carditis… resolved fully with antibiotics, avoiding permanent pacing. This case highlights Lyme carditis as a reversible cause of heart block in endemic areas. |
| Introduction | Complete heart block is usually managed with permanent pacing… However, in select reversible causes such as Lyme carditis, pacing may be avoidable… This case illustrates why etiology must be established before committing a young patient to a pacemaker. |
| Case Presentation | A 34-year-old male, previously healthy, presented with a 3-day history of dizziness and near-syncope… 2 weeks prior, he reported a hiking trip in a Lyme-endemic region and a target-shaped rash he dismissed as an insect bite… On examination, heart rate was 38 bpm, blood pressure 98/60 mmHg… ECG revealed complete atrioventricular block… |
| Investigations | Laboratory work-up showed elevated inflammatory markers… Lyme IgM and IgG were both positive, confirmed on Western blot… Echocardiogram showed mildly reduced ejection fraction with no structural abnormality… Troponin was mildly elevated, consistent with myocarditis… |
| Treatment | The patient was started on intravenous ceftriaxone for 14 days… Temporary pacing was used for hemodynamic support during the acute phase… Permanent pacemaker implantation was deferred, given the reversible nature of Lyme-associated block… |
| Outcome and Follow-Up | By day 5, the patient’s rhythm converted to normal sinus rhythm… Repeat ECG at 4 weeks showed complete resolution of atrioventricular block… At 6-month follow-up, the patient remained asymptomatic with no recurrence… |
| Discussion | This case reinforces that complete heart block in a young, otherwise healthy patient should prompt evaluation for reversible causes before permanent pacing… Lyme carditis, though rare, is well documented to cause transient high-grade block… Clinicians in endemic regions should maintain a high index of suspicion… |
| Conclusion | Lyme carditis should be considered in young patients presenting with unexplained atrioventricular block, particularly with a relevant travel or exposure history. Prompt antibiotic treatment can avoid unnecessary permanent pacemaker implantation. |
| References | 1. Jhoot, B, Lyme carditis and cardiac conduction abnormalities… 2. Ananias, C, Complete heart block in endemic Lyme regions… [3 more references] |
A quick note: this is an illustrative template only, not a real, published case. If you use a structure like this for an actual submission, every fact would need to come directly from the patient’s chart, and the references would need to be real, current citations rather than placeholders.
How Long Should a Case Report Be?
Most case reports run 500 to 1,500 words, not including the abstract, references, and tables, though this range varies by journal and discipline.
Some journals also cap the number of references, figures, and authors allowed on a case report. Always check your target journal’s author guidelines before you finalize the draft, since limits differ widely between titles.
What Is the CARE Checklist?
The CARE checklist is a 13-item guideline that authors use to make sure a medical case report is complete, transparent, and easy for editors to evaluate.
It covers the following broad areas, each with specific reporting items.
- Title and key words that identify the report as a case report.
- Abstract summarizing background, findings, and the main lesson.
- Patient information, including demographics and main concerns.
- Clinical findings, timeline, and diagnostic assessment.
- Therapeutic intervention and adherence to treatment.
- Follow-up and outcomes, including patient-reported outcomes.
- Discussion of strengths, limitations, and relevant literature.
- Patient perspective and documentation of informed consent.
Case Report Checklist Before Submission
Use the checklist below as a final review before you submit a case report to a journal.
| Checklist Item | Why It Matters |
| Clear, single teaching point stated early | Reviewers look for the reason a case deserves publication within the first paragraph. |
| Every technical term used precisely | Imprecise staging, grading, or diagnostic language is a common reason for rejection. |
| Timeline and findings internally consistent | Contradictions between sections undermine reviewer confidence in the whole report. |
| Informed consent documented | Most journals require written proof of patient or guardian consent before review. |
| Patient data de-identified | Names, exact dates, and identifying details must be removed or generalized. |
| Target journal’s format followed exactly | Section headings, word limits, and reference style differ by journal. |
| References current and relevant | Outdated or tangential references weaken the discussion section. |
| Figures and tables clearly labeled | Unlabeled or low-resolution images are a frequent cause of editorial delay. |
Best Practices for Writing a Strong Case Report
Craft a compelling title
Make it specific and jargon-free. Instead of “A Case of Cardiac Arrhythmia,” write “Complete Heart Block Following Low-Dose Ivabradine in Undiagnosed Lyme Carditis.” The second version tells a reader exactly what they will learn.
Keep it concise yet informative
Cut details that do not serve the teaching point. A patient’s unrelated childhood tonsillectomy does not need a sentence; their relevant travel history to a Lyme-endemic region does.
Ensure a thorough analysis
Do not just describe what happened; explain why. If a treatment failed, state the likely mechanism, for example, “the antibiotic was ineffective because the organism carried a resistance gene,” rather than simply noting that symptoms persisted.
End on a thought-provoking note
Close with a specific, actionable message rather than a generic summary. “Clinicians in endemic regions should screen for Lyme disease before pacemaker implantation in young patients” is stronger than “further research is needed.”
State the reason for publication early
Put the novelty claim in the first paragraph. For example, open with, “This case is among the first to document complete resolution of high-grade atrioventricular block with antibiotics alone,” rather than saving that claim for the final paragraph.
Use figures strategically
A single annotated ECG showing the block resolving over 4 weeks often communicates more than several paragraphs of text, and reviewers frequently cite strong figures as a reason a case report stood out during review.
Common Pitfalls to Avoid
- Lack of a clear research objective: an unfocused case report without a defined question or learning objective.
- Poor case selection: a case that is not representative, unique, or clinically significant.
- Overgeneralization of findings: presenting broad claims that 1 case alone cannot support.
- Ignoring ethical considerations: omitting informed consent or confidentiality safeguards.
- Incomplete data analysis: describing a case without interpreting it against relevant literature.
- Ignoring alternative explanations: presenting only 1 interpretation and introducing bias.
- Logical inconsistencies: a stated timeline or finding that contradicts a later section.
- Imprecise technical language: using staging, grading, or statistical terms loosely or interchangeably.
Key Checks for Authors
| Pitfall | Key Check | Manuscript Sections to Review |
| Lack of a clear research objective | Confirm 1 explicit question or learning objective is stated | Introduction, Abstract |
| Poor case selection | Confirm the case is unique, representative, or clinically significant | Introduction, Discussion |
| Overgeneralization of findings | Confirm claims are scoped to 1 patient, not presented as broadly applicable | Discussion, Conclusion |
| Ignoring ethical considerations | Confirm consent and confidentiality safeguards are documented | Methods, Case Presentation, Ethics Statement |
| Incomplete data analysis | Confirm findings are interpreted, not just listed | Case Presentation, Discussion |
| Ignoring alternative explanations | Confirm at least 1 alternative diagnosis or interpretation is addressed | Discussion |
| Logical inconsistencies | Cross-check every date, finding, and decision against the timeline | Case Presentation, Discussion, Timeline or Figure |
| Imprecise technical language | Confirm staging, grading, and statistical terms match the source data exactly | Case Presentation, Discussion, Abstract |
| Late or unclear novelty statement | Confirm the reason for publication appears in the first paragraph | Introduction, Discussion (opening lines) |
| Weak title or abstract alignment | Confirm the title and abstract accurately reflect the final manuscript | Title, Abstract |
A practical way to use this table is as a final read-through pass: go section by section rather than pitfall by pitfall, since several checks overlap on the same section, particularly the Discussion, which is where most of these issues tend to surface.
Ethical Considerations When Writing Case Reports
Publishing a case report always involves a real patient, so ethical safeguards apply at every stage, from the first chart review through to the final submitted manuscript.
Informed Consent
Almost every journal requires documented, written consent from the patient, or their legal guardian if the patient is a minor or unable to consent, before a case report will be considered for publication. This consent must specifically cover publication, not just treatment, since a standard clinical consent form does not extend to sharing the patient’s story in a medical journal.
Patient Confidentiality and De-Identification
Names, exact dates, medical record numbers, and any other detail that could identify the patient, alone or combined with other information in the case, must be removed or generalized. This applies to text, images, and figures alike. A photograph or scan that shows an identifying birthmark, tattoo, or facial feature needs the same care as a name would.
Institutional and Ethics Committee Review
Many institutions require a case report to go through an IRB or ethics committee, or at least receive a formal exemption determination, even though it covers only 1 patient. Checking this requirement early avoids delays later, since some journals will not accept a manuscript without documentation of this step.
Authorship and Conflicts of Interest
Everyone listed as an author should have made a real intellectual contribution to the case, not simply treated the patient or supervised the ward. Any financial or professional conflict of interest, such as a relationship with a drug manufacturer mentioned in the case, must be disclosed.
Avoiding Duplicate Publication
The same case should not be submitted to multiple journals at once, or published again elsewhere without clear acknowledgment of the earlier version. This is considered a serious breach of publication ethics, even if the second version is reworded.
A Quick Ethics Checklist
- Written consent for publication obtained and kept on file.
- All identifying details removed from text, images, and figures.
- Ethics or IRB review completed, or exemption documented.
- Every listed author made a genuine contribution.
- Conflicts of interest disclosed.
- Case not previously published or under review elsewhere.
What Is a Case Series?
A case series is a report describing 3 or more patients who share a similar condition, exposure, treatment, or outcome, presented together to reveal a pattern that a single case cannot show.
Where a case report answers the question “what happened to this 1 patient,” a case series answers a broader question: “what happens across a small group of similar patients.” This makes it a useful bridge between an isolated observation and a formal cohort study.
When a Case Series Is the Right Format
- Several patients present with the same rare condition within a short time, suggesting a common cause worth documenting.
- A cluster of patients experience the same unexpected reaction to a drug, device, or procedure.
- A clinician wants to describe outcomes across several patients treated with a new or modified technique.
- A pattern emerges across cases that would look coincidental as a single report but becomes meaningful once grouped.
Structure of a Case Series
A case series generally follows the same core sections as a case report: introduction, methods, results, and discussion. The key difference is in the results section, which typically includes a summary table listing each patient’s key characteristics, findings, and outcomes side by side, so readers can compare patients at a glance.
How a Case Series Differs From a Case Report
| Feature | Case Report | Case Series |
| Number of patients | 1 | 3 or more |
| Main purpose | Document a single unusual event or lesson | Reveal a pattern across similar patients |
| Strength of evidence | Lowest; anecdotal | Slightly stronger; suggests a trend |
| Typical structure | Introduction, case presentation, discussion | Introduction, methods, results table, discussion |
| Statistical analysis | Rarely included | Sometimes includes basic descriptive statistics |
| Common use | Rare presentation, diagnostic pitfall, adverse reaction | Confirming a pattern seen in multiple related cases |
| Word count | Usually 500 to 1,500 words | Often longer, 1,500 to 3,000 words, depending on patient count |
A Note on Generalizability
Neither format allows strong causal claims. A case series with 5 patients showing a similar drug reaction suggests a signal worth investigating further, but it cannot prove the drug caused the reaction in the way a controlled study could. Authors should state this limitation explicitly in the discussion section, rather than implying the pattern is confirmed.
Choosing Between Case Report and Case Series
If you have 1 compelling patient, write a case report. If you notice that 1 patient is actually the third or fourth similar case you have seen recently, consider whether combining them into a case series would carry more weight with reviewers than 1 report alone.
How to Choose a Journal for a Case Report Submission
Choosing the right journal matters as much as writing the case well, since even a strong manuscript can be rejected simply for not matching a journal’s scope or format.
Match the Case to the Journal’s Scope
Start with journals that regularly publish cases in the relevant specialty. A cardiology case fits a cardiology journal or a general medicine journal with a case report section, not a journal focused on public health or epidemiology.
Check Whether the Journal Accepts Case Reports at All
Some high-impact journals, such as Blood, do not have a dedicated case report category and instead publish select cases only as brief reports or letters. Confirm this before investing time in a full manuscript.
Review the Word and Reference Limits
Journals vary widely, from concise 500-word letters to detailed 1,500-word reports with expanded sections. Choosing a journal whose limits match the complexity of your case saves a difficult rewrite later.
Consider the Turnaround Time
Some case report journals offer faster peer review than general medical journals, which matters if the teaching point is time-sensitive, such as an emerging drug interaction.
Look at Recently Published Cases
Reading a few recent case reports from the target journal shows the expected tone, structure, and level of detail, and helps confirm your case is a genuine fit rather than a stretch.
Use a Presubmission Inquiry if Unsure
Many journals allow a brief presubmission inquiry, letting you confirm interest before committing to their specific template and formatting requirements.
Frequently Asked Questions
What is the difference between a case report and a case study?
In medicine, the terms are often used interchangeably, though “case study” is more common outside medicine, in fields such as business, law, and education, for an in-depth account of 1 instance or one organization.
How many patients can be included in a case report?
A case report typically covers 1 patient. Once a report covers 3 or more related patients, it is usually classified as a case series instead.
Do case reports need IRB approval?
Many institutions require IRB or ethics committee review, or at least a formal exemption determination, even for a single-patient case report, alongside signed patient consent.
Can a case report be written without patient consent?
No. Almost all journals require documented informed consent from the patient, or their legal guardian, before they will consider a case report for publication.
What is the CARE checklist used for?
The CARE checklist is used to ensure a medical case report includes all 13 recommended reporting items, from patient information to informed consent documentation.
How long does it take to get a case report published?
Timelines vary widely by journal, but many case reports move through peer review faster than full research articles, often within a few months of submission.
Can AI write a case report from scratch?
AI can produce a fast first draft, but it cannot reliably judge clinical logic, precise terminology, or genuine novelty, so a human expert review is still required.
What makes a case report get rejected by journals?
The most common reasons are poor case selection, an unclear or late teaching point, imprecise technical language, and formatting that does not match the journal’s own template.
Comment