How to Write a Case Report? |PubMed.ai Guide 2025

A medical case report is a common and educational form of academic writing, often used to document unusual or clinically significant patient cases. Writing a high-quality case report requires accurately detailing the patient’s symptoms, diagnostic process, treatment methods, and final outcomes, all organized according to a standardized case report format.

In this guide, we’ll walk you through how to write a medical case report effectively. You’ll learn the key elements of a case report, essential writing tips, and the standard case report format used in clinical research. Whether you're a medical student or healthcare practitioner, this article will help you write a well-structured and publishable clinical case study.

What is a Case Report?

A case report is a concise yet detailed account of a single patient’s clinical presentation, diagnosis, treatment, and follow-up. Typically focused on rare or novel cases, case reports contribute to medical knowledge by highlighting unusual findings or outcomes. As noted in Heart Views (the journal of the Gulf Heart Association), case reports remain “one of the cornerstones of medical progress,” providing a rapid, accessible means of sharing clinical insights—especially when large-scale research is not feasible. They often include a brief literature review and serve as a practical form of communication among busy clinicians.

For medical or surgical trainees, identifying a reportable case early in your training can be an excellent introduction to clinical research. Successfully publishing a case report not only builds your academic foundation but also adds valuable credentials to your CV.

What Kind of Cases Are Worth Reporting?

Not every clinical encounter warrants a case report. According to the ICMJE and leading medical journals, valuable case reports generally meet one or more of the following criteria:

1. Rare or Novel Presentations
   Cases involving rare diseases, unexpected symptoms, or newly observed pathological mechanisms are especially noteworthy. As highlighted by ​NEJM​, such reports can prompt new research directions or reveal previously unknown disease variants.
2. Innovative Diagnosis or Treatment
   Reports showcasing unique diagnostic tools, unconventional treatments, or novel surgical approaches—especially in complex or poorly defined conditions—offer practical insights. JAMA notes that these cases can inform clinical decision-making and inspire broader adoption of new methods.
3. Unusual Disease Course or Outcome
   As per ​The Lancet​, when a disease behaves atypically or a patient responds unexpectedly to standard treatment, documenting the case can refine medical understanding and influence future care protocols.
4. Ethical or Public Health Significance
   Cases raising important questions—like patient privacy, resource allocation, or the use of experimental therapies—can contribute to ethical discourse and policy development, as emphasized by the American Society for Bioethics and Humanities.
5. Educational Value
   Even common conditions can be report-worthy if they illustrate textbook features clearly. According to the World Federation for Medical Education, well-documented typical cases are excellent for training and reinforcing diagnostic reasoning.

Ethical Considerations and Patient Consent

Prior to writing, obtain written informed consent from the patient or their legal guardian. This is a non-negotiable requirement for publication and ensures respect for patient autonomy and privacy.

In cases involving vulnerable populations (e.g., pediatric, psychiatric, or critically ill patients), additional ethical review or institutional approval may be required.

Standard Case Report Format

Most reputable journals follow a similar structure based on the ​CARE (CAse REport) guidelines​, which help promote transparency and completeness. The typical structure includes:

1. Abstract

A concise summary (150–250 words) containing:

• Background and rationale for reporting the case
• Key clinical features and diagnosis
• Main interventions and outcome
• Conclusion and significance

2. Introduction

A brief overview of the clinical context and relevance of the condition or issue. Cite supporting literature to justify the uniqueness or educational value of the case.

3. Case Presentation

This section outlines:

• Patient demographics and history
• Presenting symptoms
• Physical examination findings
• Laboratory/imaging results
• Diagnosis
• Treatment course
• Clinical outcome and follow-up

Present information in a clear, chronological sequence. Avoid excessive detail, but include relevant timelines and decision points.

4. Discussion

The discussion should:

• Compare this case to existing literature
• Highlight what is unusual or significant
• Suggest implications for clinical practice
• Acknowledge limitations and uncertainties

Use current, peer-reviewed references to support arguments and emphasize any clinical learning points.

5. Conclusion

A brief summary emphasizing the key takeaway messages. What should clinicians remember from this case?

6. References

Follow the specific citation style of the target journal (e.g., Vancouver, AMA). Ensure all references are up-to-date and appropriately formatted.

Additional Tips for Writing an Effective Case Report

• Clarity over complexity
  Use precise, standard medical terminology, but avoid jargon or overly technical phrasing unless it is essential to the understanding of the case. A well-written report should be understandable to a broad clinical audience. As noted by the ​CARE guidelines​, clarity improves reproducibility and educational impact^[1].
• Relevance
  Focus on details that directly inform the clinical course, diagnosis, or learning value of the case. According to ​BMJ Case Reports​, excessive or unrelated information can reduce engagement and dilute the central message^[2].
• Neutral, professional tone
  Present facts objectively without emotive language. Avoid exaggeration or speculation. The New England Journal of Medicine (NEJM) editorial team emphasizes maintaining analytical neutrality even in unusual or emotional cases^[3].
• Conciseness
  Stay within the word limits set by your target journal. Redundancy not only risks rejection but also decreases the educational value. CARE guidelines recommend brevity without sacrificing key clinical reasoning steps^[1].
• Figures and tables where appropriate
  Well-designed timelines, flowcharts, radiographic images, and lab result summaries can significantly enhance understanding. Be sure to remove all personally identifiable information in accordance with ICMJE and HIPAA standards^[4].

Case Report Example (Published)

​Title​: Negative pressure pulmonary edema and hemorrhage after near fatal suffocation in an infant: a case report
​Journal​: Ital J Pediatr

​DOI​: 10.1186/s13052-025-02015-6

This case report describes a rare presentation of negative pressure pulmonary edema (NPPE) complicated by pulmonary hemorrhage in a 6-week-old male infant following near-fatal suffocation. The infant developed epistaxis and hemoptysis post-suffocation, with radiographic findings confirming alveolar hemorrhage. Diagnosis of NPPE-associated hemorrhage was established based on clinical history and imaging. Supportive therapy led to resolution of clinical symptoms within days and complete normalization of radiographic abnormalities within one month. The authors emphasize that while NPPE-related hemorrhage presents acutely, it carries a favorable prognosis with conservative management. This case underscores the critical need to consider NPPE in the differential diagnosis of pediatric pulmonary hemorrhage, particularly in patients with a history of upper airway obstruction. Timely recognition and supportive care are essential for optimal outcomes in such cases.

[Summarized by PubMed.ai]

Recommended Tools and Resources

• PubMed.ai –
  An AI-powered medical literature platform that enhances case report writing by helping you ​search​, ​analyze​, and summarize PubMed-indexed research more efficiently.

  • Use the Search Co-Pilot to refine complex queries (e.g., rare syndromes, differential diagnoses)
  • Summarize related cases using Deep Chat to extract key findings, mechanisms, or therapeutic approaches
  • Export structured PDF reports with citation-ready references and timelines for submission or inclusion in your case documentation

  Ideal for both novice writers and experienced clinicians needing to rapidly gather literature support for atypical presentations.
  👉 pubmed.ai

• PubMed (Original NIH Database)
  The foundational database for biomedical research, managed by the U.S. National Library of Medicine. Essential for locating peer-reviewed articles, MeSH-indexed studies, and clinical research worldwide.
  pubmed

• CARE Guidelines
  The official standard for case report structure and transparency. Ensures completeness and consistency across publications.
  care-statement

• BMJ Case Reports Author Toolkit
  Offers clear submission templates and formatting examples for new authors submitting to one of the leading case report journals.
  BMJ

Frequently Asked Questions (FAQs)

1. What is the difference between a medical case report and a medical case study?

A case report typically refers to a single patient's case, while a case study may include multiple cases or a broader analysis of a clinical phenomenon. However, the terms are often used interchangeably in clinical literature.

2. Can medical students write and publish case reports?

Yes. Medical students frequently write case reports, often under the supervision of faculty. It is a valuable academic exercise and a common entry point into scholarly publishing.

3. Do I need IRB approval to publish a case report?

In most cases, Institutional Review Board (IRB) approval is not required for single-patient case reports, provided that written informed consent is obtained. However, requirements may vary by institution or journal.

4. What’s the typical word count for a case report?

Most journals accept case reports between ​1,000 and 1,500 words​, excluding references and figures. Always check the submission guidelines of the target journal.

5. Which journals accept case reports?

Many journals accept case reports, including:

• BMJ Case Reports
• Journal of Medical Case Reports
• Cureus
• Case Reports in Medicine
  Some journals are open-access, while others may require subscription or institutional access.

References

1. Gagnier JJ, Kienle G, Altman DG, et al. ​The CARE guidelines: Consensus-based clinical case reporting guideline development​. J Clin Epidemiol. 2014;67(1):46–51. doi:10.1016/j.jclinepi.2013.08.003
2. BMJ Case Reports. ​Instructions for Authors​. casereports.bmj
3. Drazen JM, Ingelfinger JR. ​Reporting of case reports and series in NEJM​. N Engl J Med. Various editorials. nejm.org
4. International Committee of Medical Journal Editors (ICMJE). ​Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals​. icmje.org