Case Report Writing: Best Practices and Pitfalls to Avoid
TL;DR
- A case report documents 1 patient’s diagnosis, treatment, and outcome; it is not a substitute for original research or a case series.
- Following the CARE checklist and building a clear timeline from the first draft saves substantial revision time later.
- Written, specific patient consent and careful de-identification of text and images are non-negotiable, not final formatting steps.
- Word limits, reference limits, and abstract structure vary significantly by journal, so confirm the target journal’s current guidelines before writing.
Contents
- What Is a Case Report?
- Case Report vs Case Series vs Other Article Types
- Before You Start Writing: Pre-Writing Best Practices
- How Is a Case Report Structured?
- How to Write an Abstract for a Case Report
- Sample Case Report
- What Is the CARE Checklist and Why Does It Matter?
- Patient Consent and De-Identification: What You Need to Know
- Building the Case Timeline
- Choosing and Presenting Clinical Images
- Writing a Strong Discussion Section
- Best Practices for Case Report Writing
- Common Pitfalls to Avoid
- How Long Should a Case Report Be?
- Frequently Asked Questions
- References
What Is a Case Report?
A case report is a detailed, structured description of a single patient’s diagnosis, treatment, and outcome, usually written because the presentation is rare, the complication is unexpected, or the response to treatment is instructive for other clinicians.
Unlike original research, a case report does not test a hypothesis across a study population; it documents one clinical experience in enough detail that other physicians can recognize a similar pattern, avoid a similar error, or consider a similar treatment option. Case reports remain a valuable, citable part of the medical literature, particularly for rare diseases and novel drug reactions.
Case Report vs Case Series vs Other Article Types
Case reports are frequently confused with case series, original research, and review articles, yet each format serves a different purpose and follows different rules for length and structure. Knowing which category your work fits, before you start writing, prevents wasted effort and rejection on technical grounds.
| Article Type | Purpose | Typical Patient Number | Typical Length |
| Case Report | Documents 1 rare, unusual, or instructive patient case | 1 | 500-1500 words |
| Case Series | Documents a pattern across several related cases | 3-10 | 1500-3000 words |
| Original Research | Tests a hypothesis using a defined study population | Usually 50 or more | 3000-5000 words |
| Review Article | Synthesizes existing published literature on a topic | Not applicable | 3000-6000 words |
These figures are general guidelines, not fixed rules. Always check the target journal’s current author instructions before writing, since limits vary widely, as shown later in this article.
Before You Start Writing: Pre-Writing Best Practices
Good case reports begin long before the first sentence is drafted. Time spent in the pre-writing phase saves rework later and increases the odds of acceptance.
- Confirm the case is genuinely novel, rare, or instructive by searching the existing literature for similar reports.
- Obtain written informed consent from the patient or legal guardian early, not after the manuscript is complete.
- Identify the target journal and review its author instructions for word count, reference limits, and required reporting checklists.
- Gather all clinical data, including laboratory values, imaging results, and timeline details, before drafting begins.
Literature Search Before Writing
Searching the literature first confirms that the case is actually reportable, helps you frame exactly what makes it novel, and gives you a set of comparator cases to cite later in the discussion section. Skipping this step is one of the most common reasons a case report is rejected at initial screening, since editors quickly decline cases that turn out to be well documented already.
Steps to Search the Literature for a Case Report
| Step | What to Do |
| 1. Define search terms | Combine the diagnosis, symptom, drug, or intervention name with “case report” as a keyword. |
| 2. Search major databases | Start with PubMed or MEDLINE, then check Embase, Scopus, or Google Scholar for wider coverage. |
| 3. Check for prior similar cases | Note how many comparable cases exist and how your case differs, in presentation, outcome, or context. |
| 4. Review case report registries | Search dedicated case report journals, since some rare cases only appear there, not in general databases. |
| 5. Read reference lists | Scan citations in the closest matching articles to find older or less indexed cases. |
| 6. Set a cutoff and document it | Note your search date and terms used, since reviewers may ask how the novelty claim was established. |
| 7. Reassess novelty | Decide whether the case is the first reported instance, a rare variant, or an unusual complication, based on what you found. |
How Is a Case Report Structured?
A case report typically follows 5 sections: introduction, case description, investigations and diagnosis, treatment and outcome, and discussion, each with a distinct job to do. The table below breaks down what belongs in each section and where authors commonly go wrong.
| Section | Purpose | Typical Content | Common Errors |
| Introduction | Sets clinical context and states why the case is worth reporting | Brief background on the condition, a clear novelty statement | Too much general background; unclear or missing novelty statement |
| Case Description | Presents the patient’s history and presentation | Demographics, presenting complaint, relevant history, examination findings | Identifiable details removed inconsistently |
| Investigations and Diagnosis | Explains how the diagnosis was reached | Lab results, imaging findings, differential diagnosis | Data listed without interpretation |
| Treatment and Outcome | Describes the intervention and what happened next | Treatment given, patient’s response, length of follow-up | Follow-up too short to demonstrate a real outcome |
| Discussion | Interprets the case in the context of existing literature | Comparison with prior published cases, clinical implications, limitations | Weak literature comparison; conclusions that overreach a single case |
How to Write an Abstract for a Case Report
The abstract is usually the only part of a case report most readers see, so it needs to stand alone and justify why the case matters, without relying on the full text.
Keep it unstructured or lightly structured, depending on the journal. Many case report journals prefer an unstructured abstract of 150 to 250 words rather than the headed Background, Methods, Results format used for original research.
Elements of a case report abstract:
- Background: 1 to 2 sentences on the condition and why this case is worth reporting.
- Case presentation: patient’s age, sex, key presenting complaint, and relevant findings.
- Intervention and outcome: what was done and how the patient responded.
- Conclusion: the clinical message or takeaway for readers.
Practical tips:
- Write the abstract last, after the full manuscript is complete, so it accurately reflects the final content.
- Avoid citations, abbreviations that aren’t defined, and references to figures or tables, since the abstract must be readable in isolation.
- Do not include patient names, initials, or exact dates, the same de-identification rules apply here as in the full text.
- Include 2 to 5 keywords immediately after the abstract, one of which should be “case report,” to aid indexing and discoverability.
- Stay within the journal’s specific word limit, since abstracts are frequently rejected at screening for exceeding it.
A strong abstract answers 1 question clearly: why should a busy clinician read the rest of this case report?
Sample Case Report
Here’s an example of how a case report can be written
Title: Recurrent Syncope Revealing an Undiagnosed Cardiac Channelopathy in a Young Adult: A Case Report
Abstract
This case report describes a 24-year-old woman who presented with recurrent syncope…
Keywords
Case report, syncope, channelopathy, long QT syndrome, arrhythmia
Introduction
Syncope in young, otherwise healthy adults is usually benign, but a subset of cases…
Prior literature has documented cardiac channelopathies as an underrecognized cause of unexplained syncope, particularly…
Patient Information
The patient was a 24-year-old woman with no significant past medical history who presented to the emergency department…
She reported 3 prior episodes of transient loss of consciousness over the preceding 2 years, each occurring…
Family History
Her family history was notable for a maternal uncle who died suddenly at age 30…
Clinical Findings
On examination, the patient was alert and hemodynamically stable, with a heart rate of…
Cardiovascular examination revealed no murmurs, rubs, or gallops, and peripheral pulses were…
Timeline
| Time Point | Event |
| Day 1 | Patient presents to ED after witnessed syncopal episode… |
| Day 1 | Initial ECG performed, showing… |
| Day 2 | Cardiology consulted; further testing ordered… |
| Day 4 | Genetic testing sent; patient discharged with… |
| Week 6 | Genetic results return, confirming… |
| Month 3 | Follow-up visit; beta-blocker therapy initiated… |
Diagnostic Assessment
A 12-lead ECG obtained on admission demonstrated a corrected QT interval of…
Given the family history and ECG findings, genetic testing for known channelopathy mutations was pursued, revealing…
Differential Diagnosis
Alternative causes of syncope, including vasovagal syncope, orthostatic hypotension, and structural heart disease, were considered but…
Therapeutic Intervention
The patient was started on a beta-blocker at a dose of…
She was also counseled on lifestyle modifications, including avoidance of…
Follow-up and Outcomes
At the 3-month follow-up visit, the patient reported no further syncopal episodes and tolerated…
Repeat ECG at this visit showed…
Patient Perspective
The patient reported that understanding the genetic basis of her condition…
Discussion
This case illustrates the importance of considering inherited channelopathies in young patients presenting with recurrent syncope…
Compared with previously reported cases, this patient’s presentation was notable for…
A review of the literature identified approximately 8 comparable cases, of which…
Limitations
As with any single case report, these findings cannot be generalized, and causality between…
Conclusion
This case underscores the value of a thorough family history and targeted genetic testing in young patients with unexplained syncope…
Informed Consent
Written informed consent was obtained from the patient for publication of this case report…
References
- …
- …
- …
If you’re in a hurry to publish and structuring the case report is difficult, Editage’s Case Report Editing service can polish your manuscript and ensure adherence to unique case report formatting guidelines.
What Is the CARE Checklist and Why Does It Matter?
CARE stands for CAse REport guidelines, a checklist of 13 core items that tells authors and reviewers exactly what a complete, transparent case report should contain.
Many journals now require authors to submit a completed CARE checklist alongside the manuscript, and reviewers commonly check submissions against it. Following CARE from the first draft, rather than retrofitting a finished manuscript to match it, saves substantial revision time.
- Title: identifies the article as a case report and names the diagnosis or intervention.
- Keywords: 2 to 5 terms, including the phrase case report.
- Abstract: a brief summary of background, findings, and significance.
- Introduction: 1 or 2 paragraphs summarizing why this case is unique.
- Patient information: demographics, main concerns, and relevant medical history.
- Clinical findings: relevant physical examination and clinical findings.
- Timeline: dates and key events, presented in chronological order.
- Diagnostic assessment: methods, challenges, and reasoning behind the diagnosis.
- Therapeutic intervention: type of intervention, administration, and any changes.
- Follow-up and outcomes: clinician-assessed and patient-assessed outcomes.
- Discussion: strengths, limitations, and relevance to existing literature.
- Patient perspective: the patient’s own account of the experience, when possible.
- Informed consent: a statement confirming that consent was obtained.
Patient Consent and De-Identification: What You Need to Know
Formal ethics approval is rarely required for a single case report, but documented patient consent almost always is, and journals increasingly ask for the signed consent form itself at submission, not just a statement that consent was obtained.
- Use a written consent form, signed by the patient or their legal guardian, and keep the original on file.
- Remove names, initials, medical record numbers, and exact dates from the manuscript text.
- Avoid combining a rare diagnosis with identifying demographic details, such as an unusual occupation in a small town, since the combination itself can identify the patient.
- Obtain separate, specific written consent for any clinical photograph in which the patient could be recognized, including images where the eyes are visible.
- For deceased patients, seek consent from the next of kin; for minors, consent must come from a parent or legal guardian. Journal policy on both situations varies, so confirm it before submission.
Building the Case Timeline
CARE recommends presenting a clear timeline of the patient’s clinical course, usually as a table or figure rather than buried in prose. A well-built timeline lets reviewers and readers see, at a glance, how quickly the diagnosis was reached and how the patient responded to treatment.
Elements of the Case Timeline
- Date or day number of symptom onset.
- Date of first presentation to a clinician or facility.
- Dates of key investigations, such as imaging or laboratory tests.
- Date of diagnosis.
- Date and type of treatment or intervention.
- Dates of follow-up visits and the final outcome.
Choosing and Presenting Clinical Images
Clinical images, including photographs, radiology, and pathology slides, strengthen a case report but come with technical and ethical requirements that authors frequently overlook.
- Submit images at a minimum resolution of 300 dpi, in the file format the journal specifies, usually TIFF or JPEG.
- Write a concise caption for each image, explaining what it shows and its clinical relevance.
- Do not rely on a black bar over the eyes to de-identify a photograph; some journals reject this method outright, since other features can still be recognizable.
- Obtain, and where required submit, written consent specific to each identifiable image, separate from general case consent.
Writing a Strong Discussion Section
The discussion section is where many otherwise solid case reports fall short, usually because the literature comparison is thin or the conclusions reach further than a single patient can support.
- State clearly whether the case is the first reported instance, a rare variant, or an unusual complication of a known condition.
- Cite roughly 5 to 10 comparable published cases to place the finding in context, not just 1 or 2.
- Discuss the clinical implications for diagnosis or treatment, not only the case’s rarity or curiosity value.
- Acknowledge the limitations of a single case report, since it cannot establish causation or generalize to other patients.
Best Practices for Case Report Writing
- Follow the CARE checklist from the first draft, not as a final formatting step.
- Keep the writing clear, concise, and free of unnecessary jargon.
- Use past tense for the patient’s history and present tense for established medical facts.
- Ask a colleague or a professional medical editor to review the manuscript before submission.
Common Pitfalls to Avoid
Delaying Patient Consent Until After the Manuscript Is Drafted
Writing first and seeking consent later is one of the most frequent, and most avoidable, reasons a case report stalls. If the patient declines, is unreachable, or requests changes late in the process, the entire manuscript may need rework or abandonment. Obtain written consent during the pre-writing phase, before investing time in drafting.
Omitting a Clear Statement of Why the Case Is Novel
Reviewers look for an explicit novelty statement, usually in the introduction, explaining whether the case is the first reported instance, a rare variant, or an unexpected complication. Without this, editors often assume the case is simply “interesting” rather than publishable, which is a common reason for early rejection.
Presenting Laboratory or Imaging Data Without Interpreting Its Clinical Significance
Listing lab values, scan findings, or vital signs without explaining what they mean for the diagnosis leaves readers to do the interpretive work themselves. Every data point included should connect directly to the diagnostic reasoning or clinical decision it supported.
Citing Too Few, or Outdated, Comparator Cases in the Discussion
A discussion built on 1 or 2 old references does not convincingly establish novelty or context. Aim for 5 to 10 recent, comparable published cases, and be explicit about how the current case resembles or differs from them.
Exceeding the Target Journal’s Word Count or Reference Limit
Word and reference limits vary significantly by journal, and manuscripts that exceed them are often returned before peer review even begins. Confirm the exact limits early, and edit toward that target throughout drafting rather than cutting content at the end.
Leaving Identifiable Patient Details in the Text, Tables, or Images
Names, initials, exact dates, medical record numbers, and identifiable combinations of demographic details must be removed from every part of the manuscript, not just the case description. Images require separate scrutiny, since features beyond the face, such as tattoos or rare surgical scars, can also identify a patient.
How Long Should a Case Report Be?
Word limits vary widely by journal, from about 1000 words to 2000 words or more, so authors should always confirm the exact limit in the target journal’s current author guidelines before writing.
| Journal | Word Limit | Abstract Type | Reference Limit |
| BMJ Case Reports | Around 2000 words, excluding references | Structured summary section | Not fixed; use only essential references |
| Clinical Case Reports Journal | 1500-2000 words | Structured; length varies by article type | Not specified for case reports |
| BMC Journal of Medical Sciences | Up to 1500 words | Unstructured, up to 200 words | Not specified for case reports |
These examples are illustrative and current as of the guidelines reviewed for this article. Journals update their policies periodically, so confirm current requirements directly with the target journal before submission.
Frequently Asked Questions
What Is the Ideal Word Count for a Case Report?
Most journals expect 500 to 2000 words, excluding the abstract and references, but the exact limit depends entirely on the target journal, so check its current author guidelines first.
How Many Authors Can Be Listed on a Case Report?
Many journals cap case report authorship at around 3 to 5 individuals, reflecting the relatively limited scope of a single-patient report. Check the target journal’s specific policy, since limits vary.
Do You Need Institutional Review Board Approval for a Case Report?
Formal institutional review board approval is usually not required for a single case report, but documented, signed patient consent almost always is, and some journals request the consent form itself at submission.
What Is the Difference Between a Case Report and a Case Study?
In medical publishing, the terms are generally used interchangeably to describe a report of a single patient. In other fields, such as business or psychology, case study often refers to a broader qualitative research method.
Can a Case Report Be Published Without Patient Consent?
No. Reputable journals will not send a case report for review without documented consent from the patient or their legal guardian, and this requirement stands regardless of how thoroughly the manuscript is de-identified.
How Do You Make a Case Report Truly Novel?
Search the existing literature thoroughly before writing, then state explicitly whether the case is the first reported instance, a rare variant, or an unexpected complication or drug reaction.
What Reporting Guideline Should You Follow for a Case Report?
The CARE checklist, consisting of 13 core items, is the most widely recognized reporting guideline for case reports and is required or recommended by many peer-reviewed journals.
Can a Single Case Report Include Multiple Patients?
A true case report describes 1 patient. Once a manuscript covers 3 or more related patients, most journals reclassify it as a case series, which follows a different structure and length limit.
References
- Guidelines to writing a clinical case report. Heart Views. 2017;18(3):104-5.
- BMJ Case Reports. How to write a case report [Internet]. London: BMJ Publishing Group; [cited 2026 Jul 8]. Available from: https://info.bmj.com/view/1071031049/
- Chakrabarti S, Mandal PK, Dasgupta S. Writing medical case report: a primer for the beginners. J Hematol Allied Sci. 2024;4(1):11-5.
- Savige J. How to write a case report [Internet]. Sydney: Royal Australasian College of Physicians; [cited 2026 Jul 8]. Available from: https://www.racp.edu.au/docs/default-source/trainees/training-resources/divisional-clinical-examination/how-to-write-a-case-report-professor-judy-savige.pdf
This article was originally published on May 26, 2025, and updated on July 3, 2026.
