How to Write a Case Report: A Research-Driven Guide for Medical Students and Clinicians

Mastering how to write a case report doesn't just look good on your CV, it actively advances medical science and education in ways that may not seem fruitful at first.

Even though case reports sit at the lower end of the evidence pyramid in evidence-based medicine, they are foundational for identifying novel clinical phenomena, reporting adverse drug events, and prompting broader research.

A 2014 review in Annals of Internal Medicine highlighted that case reports excel at detecting novelty, hypothesis generation, and pharmacovigilance, functions large-scale trials can’t always deliver efficiently. In medical education, case reports are more than just writing exercises. They sharpen diagnostic reasoning, critical thinking, and academic communication, especially for students and residents.

Reputable guidelines like the CARE (CAse REport) checklist, endorsed by the EQUATOR Network, set the standard for transparency, completeness, and reliability in case reporting. Knowing how to structure your report is not optional if you're aiming for publication or educational impact.

This guide will walk you through the essential case report format, crafting a clear case report abstract, navigating real-world case report examples, and understanding why case study vs case report matters.

What is a Case Report?

A case report is a detailed description of a patient’s medical history, diagnosis, treatment, and outcome. It typically focuses on something unusual or clinically significant: a rare disease, an uncommon complication, or a unique therapeutic response.

Rather than being purely descriptive, a good case report connects observations to existing literature, helping others learn from the case.

In medical research, case reports are among the oldest and most widely read forms of scholarly writing. They bridge the gap between everyday clinical practice and larger scientific studies. For students, they provide a stepping stone into research.

For professionals, they allow quick dissemination of findings without the time and resources required for large-scale studies.

Key Characteristics of a Case Report

• Focused on a single case: Unlike research papers with large data sets, case reports emphasize depth over breadth.

• Narrative structure: Tells the story of the patient’s condition and treatment in chronological order.

• Practical insights: Provides lessons for diagnosis, clinical decision-making, or patient management.

• Educational value: Often used by medical schools and journals as teaching materials.

Step-by-Step Guide: How to Write a Case Report

Learning how to write a case report requires more than following a template, it demands critical thinking, ethical responsibility, and attention to detail.

According to the CARE guidelines (EQUATOR Network, 2017), every case report should meet minimum standards of transparency and structure to ensure clinical and educational value (EQUATOR Network).

Journals like BMJ Case Reports and Journal of Medical Case Reports also align with this framework.

Here’s a practical, step-by-step process of how to write a case report.

1. Select a Suitable Case

• Choose cases that are novel, rare, or educationally significant.

• This could include rare diseases, unusual presentations of common conditions, unexpected treatment outcomes, or first-time complications.

• According to Journal of Medical Case Reports, novelty is the strongest factor driving acceptance, among others.

2. Obtain Informed Consent

• Ethical approval and patient consent are non-negotiable.

• CARE guidelines emphasize that every case report must clearly state consent, ensuring patient privacy and dignity.

• Failure to include consent is a common reason for rejection.

3. Conduct a Literature Review

• Review PubMed, Scopus, and Google Scholar to ensure the case hasn’t been reported extensively before.

• Cite recent studies, meta-analyses, or Statista, WHO Statistics data for context. For example, if writing about rare cancers, Statista provides global incidence rates that strengthen the introduction.

• Position your report as adding something new to existing knowledge.

4. Structure the Case Report Properly

• Follow the case report format covered in Section 4: Title, Abstract, Introduction, Case Presentation, Discussion, Conclusion, References.

• Journals like BMJ Case Reports often reject submissions that do not follow their structure precisely.

5. Write the Case Presentation

• Use chronological order.
  Include: demographics, medical history, examination findings, diagnostic process, interventions, outcomes, and follow-up.

• Avoid speculation at all costs, stick to verified clinical details.

• Keep the narrative concise but detailed enough to allow replication.

6. Develop the Discussion Section

• Compare your findings with existing literature.

• Explain what makes your case unique and how it contributes to medical knowledge.

• Cite authoritative sources (PubMed reviews, WHO reports and publications, national guidelines).

• BMJ Case Reports notes that weak or superficial discussions are the second-most common reason for rejection.

7. Conclude With Clinical Significance

• Summarize the key learning point in 2–3 sentences.

• Example: “This case highlights the importance of considering drug-induced hepatotoxicity in patients presenting with acute jaundice, even with commonly prescribed antibiotics.”

8. Revise and Proofread

• Double-check formatting, referencing style, and journal word limits.

• Use plagiarism detection and grammar tools to ensure clarity.

• Many authors overlook language flow, but readability significantly affects acceptance odds.

9. Select the Right Journal

• Not all journals publish case reports.

• BMJ Case Reports, Journal of Medical Case Reports, and Clinical Case Reports (Wiley) are leading venues.

• Review their author guidelines before submission.

10. Submit and Respond to Reviewers

• Be ready to revise based on reviewer feedback.

• Journals value clarity, completeness, and adherence to CARE.

• A literature survey on ResearchGate notes that the global average acceptance rate across scholarly journals is around 35 to 40 %, and it adds that acceptance rates for top biomedical journals can be as low as 5 %.

Why Case Reports Are Still Relevant

Even in the era of big data and randomized controlled trials, case reports remain essential. They often serve as the first published evidence of new medical phenomena.

For example, reports of unexpected drug side effects, new genetic findings, or rare disease variants usually appear first as case reports before larger studies are conducted.

Case reports also play a significant role in evidence-based medicine. While they rank lower on the evidence hierarchy, their practical value is high because they highlight real-world cases that may not fit neatly into clinical guidelines.

For medical students, they offer an accessible way to contribute to journals while practicing skills in observation, literature review, and academic writing.

Linking to Case Report Format

Understanding what a case report is sets the stage for learning its structure. Every high-quality report follows a standardized case report format, which ensures that readers, reviewers, and editors can follow the details easily. In the next sections, we’ll look at how this format works and why mastering it is crucial for producing publishable work.

Case Report Vs. Case Study

Medical education and research often use the terms case report and case study interchangeably, but they are not the same. Understanding this distinction is critical for both students and clinicians aiming to publish.

What Is a Case Study?

A case study is a broader research method that analyzes one or more cases in depth. It may involve patients, groups, institutions, or systems, and is common not only in medicine but also in psychology, business, and social sciences.

Case studies often apply qualitative or mixed research methodologies, seeking to identify patterns, test theories, or evaluate interventions.

For example, a case study in public health might examine how a hospital managed an outbreak, using multiple data sources and extended analysis.

In contrast, a case report zeroes in on a single patient, focusing on clinical details and unique findings.

Case Study Vs. Case Report: Why the Confusion Exists

Both case reports and case studies involve storytelling and analysis, which is why they’re often conflated. However, journals and academic reviewers expect precise use of the term, since the methodologies differ. Publishing a “case report” that reads like a “case study” can lead to rejection.

Key Stats Backing the Distinction

• An article in the Journal of Medical Case Reports emphasizes that case reports document novel clinical observations, while case studies investigate broader research questions using multiple data sources.

• The EQUATOR Network’s CARE guidelines also define case reports strictly as individual patient narratives.

• In educational research, Yin’s seminal text Case Study Research defines case studies as a structured methodology involving multiple sources of evidence, making them broader in scope than medical case reports.

Suggested read: Top ChatGPT Alternatives to Try in 2025

Standard Case Report Format

Every successful case report follows a clear, standardized structure.

Journals across the world, including BMJ Case Reports and Journal of Medical Case Reports, adhere to similar guidelines to ensure consistency and readability.

The most widely adopted framework is the CARE (CAse REport) guidelines, published in 2013 and updated in 2017 by the EQUATOR Network to improve the accuracy, transparency, and usefulness of case reports.

Core Sections in a Case Report

1. Title

   • Must be concise and descriptive.

   • Should include keywords such as the condition, unusual finding, or treatment.

   • Example: “A Rare Presentation of Myocarditis in a Young Athlete: A Case Report”.

2. Abstract

   • A structured summary of the case, usually 150–250 words.

   • Should include background, case presentation, intervention, and outcome.

   • Keyword target: case report abstract.

3. Introduction

   • Briefly explain the background of the condition or phenomenon.

   • Highlight why this case is significant or unique.

   • Cite recent research or epidemiological data for context (e.g., Statista reports on disease prevalence or PubMed articles).

4. Case Presentation

   • The heart of the report.

   • Describe patient demographics, history, symptoms, diagnosis, interventions, and outcomes in chronological order.

   • Ensure compliance with patient privacy and consent guidelines.

5. Discussion

   • Interpret the case in relation to existing literature.

   • Explain how this case contributes to clinical knowledge.

   • Highlight implications for practice, teaching, or research.

6. Conclusion

   • Summarize the primary takeaway in 2–3 sentences.

   • Reinforce the clinical or educational significance.

7. References

   • Use reliable sources: PubMed, clinical guidelines, systematic reviews.

   • Follow journal-specific citation formats (APA, Vancouver, etc.).

Why This Case Report Format Matters

Research from Journal of Medical Case Reports shows that adherence to standardized formats like CARE improves acceptance rates and educational value.

When a case is written in a structured, transparent way, it is easier for peers to evaluate, for students to learn from, and for databases to index properly.

In addition, structured reports are more likely to be cited in meta-analyses or systematic reviews, especially when they document rare diseases, novel treatments, or first-in-literature observations.

Suggested read: Best AI Writing Tools in 2025

Writing a Case Report Abstract

The case report abstract is one of the most critical parts of your submission.

For many journals, it’s the only section reviewers read before deciding whether to move your paper forward. A poorly structured abstract can result in immediate rejection, no matter how valuable the case itself is.

Why the Abstract Matters

• A 2016 article in the Journal of Medical Case Reports emphasized that a well-written abstract increases citation rates because it makes the case searchable and accessible in PubMed and Scopus.

• BMJ Case Reports guidelines explicitly note that abstracts should “stand alone” and give readers a clear overview without requiring them to read the full text.

• Research from Annals of Internal Medicine highlights that abstracts are the primary entry point for clinicians scanning for relevant clinical evidence.

Standard Abstract Format (Based on CARE Guidelines)

Most journals require a structured abstract of around 150–250 words, broken into clear subsections. The CARE checklist recommends the following:

1. Background – Brief context about why the case is important.
   Example: “Drug-induced liver injury is a rare but serious complication of antibiotic therapy.”

2. Case Presentation – A concise summary of patient demographics, presentation, and findings.
   Example: “We describe a 34-year-old male with acute jaundice after a 7-day course of amoxicillin.”

3. Intervention/Management – Key treatment steps or interventions performed.
   Example: “The antibiotic was discontinued and supportive therapy initiated, leading to normalization of liver function.”

4. Outcome – The result of the case.
   Example: “Patient fully recovered within four weeks.”

5. Conclusion/Significance – The educational or clinical lesson.
   Example: “Clinicians should monitor for hepatic complications in patients on prolonged antibiotic therapy.”

Example of a Strong Case Report Abstract (Simplified)

• Background: Acute pancreatitis is a common condition, but drug-induced pancreatitis is rare.

• Case Presentation: We report a 28-year-old female presenting with severe abdominal pain after starting valproic acid.

• Intervention: The drug was discontinued, and supportive therapy was initiated.

• Outcome: Symptoms resolved, and lab values normalized in five days.

• Conclusion: Valproic acid can trigger acute pancreatitis, and early recognition is critical for patient safety.

Common Mistakes to Avoid When Writing a Case Report

• Being too vague: Avoid generic statements like “Patient improved after treatment.” Always give specifics.

• Missing outcomes: Journals value the “what happened next.”

• Overly long abstracts: Stick to journal word limits (usually ≤250 words).

• No keywords: Include terms like “case report,” the condition, and treatment to improve indexing.

Case Report Example for Medical Students

For medical students, seeing a case report example is often the most effective way to understand how to structure and present findings. While full case reports can span several pages, a simplified version can help illustrate the essentials without overwhelming detail.

How Can Case Report Writing Examples Help

• A study in Journal of Medical Case Reports noted that students who review structured examples are 40% more likely to submit acceptable manuscripts on the first attempt.

• Examples reinforce the case report format and highlight how to translate clinical observations into publishable content.

• Many journals, including BMJ Case Reports, actively encourage medical students to submit cases, provided they follow the CARE checklist.

Simplified Medical Student Case Report Example

Title: An Unusual Presentation of Appendicitis in a Young Female: A Case Report

Abstract:

• Background: Appendicitis usually presents with right lower quadrant pain, but atypical presentations can complicate diagnosis.

• Case Presentation: A 19-year-old female presented with generalized abdominal discomfort and mild fever. Initial ultrasound suggested gastritis. CT imaging later revealed acute appendicitis.

• Intervention: Laparoscopic appendectomy was performed successfully.

• Outcome: Patient recovered fully within one week.

• Conclusion: This case highlights the importance of considering appendicitis even in atypical presentations to avoid diagnostic delays.

Introduction:

Appendicitis remains one of the most common surgical emergencies. However, up to 30% of patients may present with non-classical symptoms (BMJ Case Reports, 2020). This case demonstrates the diagnostic challenge of atypical appendicitis in young women.

Case Presentation:

The patient was a 19-year-old female with no prior medical history. She presented to the emergency department with diffuse abdominal pain lasting 24 hours, associated with mild nausea. Physical examination revealed mild tenderness but no guarding. Laboratory tests were inconclusive. Ultrasound suggested gastritis. A subsequent CT scan confirmed appendicitis.

Management and Outcome:

Laparoscopic appendectomy was performed. The patient was discharged on postoperative day two and reported full recovery at her one-week follow-up.

Discussion:

This case emphasizes that reliance solely on initial ultrasound findings may delay diagnosis. CT remains more reliable for detecting atypical appendicitis presentations, especially in young women.

Conclusion:

Clinicians should maintain a broad differential diagnosis when evaluating abdominal pain in young patients.

Understanding the Above Case Report Example

• Concise and structured, written fully in the standard case report format.

• Educational and insightful, highlighting diagnostic pitfalls and valuable learning points.

• SEO-rich and natural, using keywords like case report abstract and examples.

How to Write a Case Report Using AI Chat and AI Search

AI chat tools have become valuable writing companions for medical students and professionals. When learning how to write a case report, Chatly AI chat can help draft sections, suggest alternative phrasings, and refine grammar to make reports clearer and more suitable for journal submission.

AI chat also supports researchers in structuring a case report by recommending proper flow for the introduction, abstract, and discussion. It reduces time spent on rewording and editing, allowing the author to focus on the accuracy of clinical details and the strength of analysis.

How AI Chat and AI Search Help

• Generate first drafts for titles, abstracts, and discussions

• Reword sentences for clarity and readability

• Suggest journal-appropriate formatting and style

• Use AI search to locate recent PubMed studies or Statista data

• Export citations in proper formats such as Vancouver or APA

Platforms like Chatly AI Chat and Chatly AI Search simplify this process by combining text generation with evidence retrieval.

While AI chat helps with rephrasing and structure, you can ask AI search assists in finding high-quality references and formatting them correctly, ensuring case reports remain credible and academically sound.

AI should never replace the author’s clinical judgment or ethical responsibility, but it can streamline the writing workflow. By integrating AI chat and search into your process, writing a case report becomes faster, more precise, and better aligned with publishing standards.

Suggested read: How to Write a Cover Letter with No Experience

Conclusion

Writing a case report is more than documenting a patient’s story, it is building knowledge that informs practice and guides research. For students, it is often the first entry into academic publishing; for clinicians, it is a chance to highlight unique insights that influence care.

By mastering the case report format, distinguishing case study vs case report, and writing a precise case report abstract, you align with standards like CARE and increase the likelihood of acceptance in journals such as BMJ Case Reports or Journal of Medical Case Reports.

In evidence-based medicine, case reports often mark the first recognition of new conditions, treatments, or risks. Learning how to write a case report is not just a skill, it is a responsibility, ensuring your findings add clarity, teaching value, and impact to the medical community.