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How to write a medical case report

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• Seema Biswas , editor-in-chief, BMJ Case Reports, London, UK ,
• Oliver Jones , student editor, BMJ Case Reports, London, UK

Two BMJ Case Reports journal editors take you through the process

This article contains...

- Choosing the right patient

- Choosing the right message

- Before you begin - patient consent

- How to write your case report

- How to get published

During medical school, students often come across patients with a unique presentation, an unfamiliar response to treatment, or even an obscure disease. Writing a case report is an excellent way of documenting these findings for the wider medical community—sharing new knowledge that will lead to better and safer patient care.

For many medical students and junior doctors, a case report may be their first attempt at medical writing. A published case report will look impressive on your curriculum vitae, particularly if it is on a topic of your chosen specialty. Publication will be an advantage when applying for foundation year posts and specialty training, and many job applications have points allocated exclusively for publications in peer reviewed journals, including case reports.

The writing of a case report rests on skills that medical students acquire in their medical training, which they use throughout their postgraduate careers: these include history taking, interpretation of clinical signs and symptoms, interpretation of laboratory and imaging results, researching disease aetiology, reviewing medical evidence, and writing in a manner that clearly and effectively communicates with the reader.

If you are considering writing a case report, try to find a senior doctor who can be a supervising coauthor and help you decide whether you have a message worth writing about, that you have chosen the correct journal to submit to (considering the format that the journal requires), that the process is transparent and ethical at all times, and that your patient is not compromised in your writing. Indeed, try to include your patient in the process from the …

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The Ultimate Guide to Writing a Medical Case Study

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In the world of healthcare, medical case studies play a crucial role in advancing our understanding of different diseases, treatment approaches, and patient outcomes. They provide a detailed analysis of individual cases, highlighting the challenges faced, the diagnostic process, treatment plans, and ultimately the outcomes. If you're a medical professional looking to contribute to the body of knowledge in your field, or if you're a student studying medicine, learning how to write an effective medical case study is an essential skill. In this ultimate guide, we will walk you through the process of crafting a comprehensive and informative medical case study, from understanding its importance to writing and refining the final piece.

Understanding the Importance of a Medical Case Study

Medical case studies serve as valuable resources for healthcare professionals, researchers, and students alike. They provide insights into rare or complex conditions, new treatment methodologies, and even potential areas for further research. By analyzing the intricate details of a specific case, medical professionals can enhance their knowledge and decision-making abilities. Medical case studies also contribute to evidence-based medicine, as they provide real-life examples that showcase the effectiveness or shortcomings of certain treatment approaches.

The Role of Medical Case Studies in Healthcare

Medical case studies are not just academic exercises; they have practical implications in the field of healthcare. By examining case studies , healthcare professionals can gain a deeper understanding of diseases, symptoms, and treatment options. They can also increase their ability to diagnose and treat similar cases effectively. Additionally, medical case studies can assist in identifying patterns or commonalities among patients, leading to potential breakthroughs in research and the development of new treatment protocols.

Key Elements of a Successful Medical Case Study

Before diving into the writing process, it's crucial to understand the key elements that make up a successful medical case study.

• Patient Selection: Choose a case that is both medically interesting and representative of a broader medical issue.
• Data Collection: Gather comprehensive and accurate information about the patient's history, symptoms, diagnostic tests, treatment options, and outcomes.
• Analyzing and Interpreting Data: Analyze the collected data to identify patterns, trends, and potential treatment approaches. Interpret the results to draw meaningful conclusions.
• Clear Communication: Present the case study in a well-structured manner, using clear and concise language to effectively communicate your findings.

Furthermore, medical case studies often involve collaboration between healthcare professionals from different specialties. This interdisciplinary approach allows for a more comprehensive understanding of the case and encourages the exchange of knowledge and expertise. It is through this collaboration that innovative treatment strategies can be developed and implemented.

In addition to their educational and research value, medical case studies also play a crucial role in medical ethics. They provide a platform for discussing ethical considerations in patient care, such as informed consent, privacy, and the balance between patient autonomy and beneficence. By examining these ethical dilemmas within the context of a real-life case, healthcare professionals can develop a deeper appreciation for the complexities of medical decision-making.

Overall, medical case studies are a vital tool in the field of healthcare. They offer a wealth of information and insights that can improve patient care, advance medical knowledge, and shape future research. By carefully documenting and sharing these cases, healthcare professionals contribute to the continuous improvement of medical practice and the well-being of patients worldwide.

Preparing to Write Your Medical Case Study

Writing a medical case study requires careful preparation to ensure accuracy and ethical considerations are upheld throughout the process. It is essential to approach this task with diligence and attention to detail to provide a comprehensive and informative analysis.

When embarking on the journey of crafting a medical case study, one must delve deep into the intricacies of the patient's condition, treatment, and outcomes. This in-depth exploration not only enriches the study but also contributes to the body of medical knowledge, potentially aiding in the understanding and management of similar cases in the future.

Gathering and Organising Your Data

Start by gathering all relevant patient information, including medical records, test results, and any additional documentation. Organize the information in a logical order, ensuring that you have a complete and comprehensive picture of the case. This will facilitate the writing process and help you stay focused on the critical aspects of the case.

Delving into the archives of medical history, one must sift through the plethora of data with a discerning eye, extracting the essential details that form the backbone of the case study. By meticulously organising this wealth of information, you lay the foundation for a structured and coherent narrative that will guide readers through the complexities of the medical scenario.

Ethical Considerations in Medical Case Studies

Before proceeding with writing your case study, it is essential to consider and address any ethical considerations. Protect patient confidentiality by de-identifying personal information and obtaining informed consent when necessary. Adhere to ethical guidelines and ensure that no harm is caused to the patient.

Ethical integrity forms the cornerstone of medical research and documentation. Upholding the principles of beneficence, non-maleficence, and respect for autonomy is paramount in the creation of a medical case study. By navigating the intricate web of ethical considerations with care and prudence, you demonstrate a commitment to the well-being and rights of the individuals involved in the study.

Structuring Your Medical Case Study

A well-structured medical case study is crucial for effectively conveying information and maintaining the reader's interest. Dividing your case study into distinct sections helps provide a logical flow and enhances readability.

The Introduction: Setting the Scene

Begin your case study by providing background information on the specific medical condition or problem you are addressing. This section should set the scene for the case study, providing context and highlighting the significance of the case.

The Patient's Medical History

Outline the patient's medical history, including relevant past conditions, previous treatments, and any predisposing factors that may have influenced the current case. Provide a detailed timeline of events leading up to the diagnosis.

The Diagnosis and Treatment Process

Detail the diagnostic process, including initial assessments, tests, and consultations with specialists. Describe the reasoning behind the chosen diagnostic approach and provide a clear explanation of how the final diagnosis was reached. After the diagnosis, document the treatment plan, discussing the rationale and any challenges that arose during the process.

The Outcome and Follow-up

Conclude your case study by describing the outcome of the treatment, including any improvements or complications. Discuss the follow-up care provided, as well as the patient's prognosis and long-term outlook.

Furthermore, it is important to consider the ethical implications of your case study. Medical professionals must always prioritize patient confidentiality and obtain informed consent before sharing any personal information. Respecting the patient's privacy is paramount, and any identifying details should be anonymized to protect their identity.

Additionally, including relevant research and evidence-based practice in your case study can strengthen its credibility. Referencing current literature and studies that support your diagnostic and treatment decisions can provide a solid foundation for your findings. This demonstrates your commitment to staying up-to-date with the latest advancements in the field and ensures that your case study is based on sound medical knowledge.

Writing and Refining Your Medical Case Study

Now that you have gathered all the necessary information and structured your case study, it's time to focus on the writing process.

Writing a medical case study is no easy task. It requires meticulous attention to detail, a deep understanding of the subject matter, and effective communication skills. As you embark on this journey, let's explore some additional tips and insights to help you craft a comprehensive and impactful case study.

Tips for Clear and Concise Writing

Effective communication is key when presenting a medical case study. Use clear and concise language to convey your information, avoiding unnecessary jargon or complex terminology. By doing so, you ensure that your case study is accessible to a wider audience, including healthcare professionals from different specialties. Remember, simplicity is the ultimate sophistication.

In addition to using plain language, it is essential to break your writing into paragraphs. This not only enhances the readability of your case study but also allows for better organization and flow of information. Consider using headings and subheadings to highlight key points and guide your readers through the different sections of your study.

The Importance of Medical Terminology

While clear communication is vital, it is equally important to use appropriate medical terminology in your case study. Precise and accurate descriptions of medical conditions, tests, procedures, and treatments not only enhance the credibility of your study but also ensure that fellow healthcare professionals can fully comprehend and appreciate your findings.

However, striking the right balance is crucial. Avoid overwhelming your readers with an excessive amount of technical terms. Instead, provide explanations and definitions where necessary, allowing for a comprehensive understanding of the case study without alienating those who may not be familiar with every medical term.

Proofreading and Editing Your Case Study

Before finalizing your case study, it is imperative to thoroughly proofread and edit your work. Pay close attention to grammatical errors, typos, and inconsistencies in formatting. A polished and error-free case study not only reflects your professionalism but also ensures that your message is conveyed accurately.

Furthermore, take the time to assess the overall flow and logical structure of your writing. Does the information progress in a coherent manner? Are the key points effectively highlighted? Consider seeking feedback from colleagues or mentors to gain a fresh perspective on your case study's clarity and effectiveness. Constructive criticism can be invaluable in refining your work and elevating the quality of your study.

Writing a medical case study is a challenging yet rewarding endeavor. It allows you to contribute to the body of medical knowledge while showcasing your expertise as a healthcare professional. By following the steps outlined in this ultimate guide, you can create a compelling and informative case study that not only adds value to the field but also serves as a testament to your dedication and commitment to advancing healthcare.

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• Published: 30 January 2023

A student guide to writing a case report

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As a student, it can be hard to know where to start when reading or writing a clinical case report either for university or out of special interest in a Journal. I have collated five top tips for writing an insightful and relevant case report.

A case report is a structured report of the clinical process of a patient's diagnostic pathway, including symptoms, signs, diagnosis, treatment planning (short and long term), clinical outcomes and follow-up. 1 Some of these case reports can sometimes have simple titles, to the more unusual, for example, 'Oral Tuberculosis', 'The escapee wisdom tooth', 'A difficult diagnosis'. They normally begin with the word 'Sir' and follow an introduction from this.

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Guidelines To Writing a Clinical Case Report. Heart Views 2017; 18 , 104-105.

British Dental Journal. Case reports. Available online at: www.nature.com/bdj/articles?searchType=journalSearch&sort=PubDate&type=case-report&page=2 (accessed August 17, 2022).

Chate R, Chate C. Achenbach's syndrome. Br Dent J 2021; 231: 147.

Abdulgani A, Muhamad, A-H and Watted N. Dental case report for publication; step by step. J Dent Med Sci 2014; 3 : 94-100.

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Harvard T.H. Chan School of Public Health Case-Based Teaching & Learning Initiative

Teaching cases & active learning resources for public health education, writing a case.

An overview of the case planning and writing process, by experienced case-writer and CBTL workshop leader Kirsten Lundberg.

2019. The Case Centre . Visit website A non-profit clearing house for materials on the case method, the Case Centre holds a large and diverse collection of cases, articles, book chapters and teaching materials, including the collections of leading business schools across the globe.

Abell, D. , 1997. What makes a good case? . ECCHO–The Newsletter of the European Case Clearing House , 17 (1) , pp. 4-7. Read online "Case writing is both art and science. There are few, if any, specific prescriptions or recipes, but there are key ingredients that appear to distinguish excellent cases from the run-of-the-mill. This technical note lists ten ingredients to look for if you are teaching somebody else''s case - and to look out for if you are writing it yourself."

Roberts, M.J. , 2001. Developing a teaching case (abridged) , Harvard Business School Publishing. Publisher's Version A straightforward and comprehensive overview of how to write a teaching case, including sections on what makes a good case; sources for and types of cases; and steps in writing a case.

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How to Write a Medical Case Study Report

Last Updated: April 18, 2024 Approved

This article was medically reviewed by Mark Ziats, MD, PhD and by wikiHow staff writer, Jennifer Mueller, JD . Dr. Mark Ziats is an Internal Medicine Physician, Scientist, Entrepreneur, and the Medical Director of xBiotech. With over five years of experience, he specializes in biotechnology, genomics, and medical devices. He earned a Doctor of Medicine degree from Baylor College of Medicine, a Ph.D. in Genetics from the University of Cambridge, and a BS in Biochemistry and Chemistry from Clemson University. He also completed the INNoVATE Program in Biotechnology Entrepreneurship at The Johns Hopkins University - Carey Business School. Dr. Ziats is board certified by the American Board of Internal Medicine. There are 15 references cited in this article, which can be found at the bottom of the page. wikiHow marks an article as reader-approved once it receives enough positive feedback. In this case, 100% of readers who voted found the article helpful, earning it our reader-approved status. This article has been viewed 189,509 times.

You've encountered an interesting and unusual case on your rounds, and a colleague or supervising physician says, "Why don't you write up a case study report?" If you've never written one before, that might sound intimidating, but it's a great way to get started in medical writing. Case studies always follow a standard structure and format, so the writing is very formulaic once you get the hang of it. Read on for a step-by-step guide to writing your first case study report.

What is a case study report?

• Medical students or residents typically do the bulk of the writing of the report. If you're just starting your medical career, a case study report is a great way to get a publication under your belt. [2] X Research source

• If the patient is a minor or is incapable of giving informed consent, get consent from their parents or closest relative. [4] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source
• Your hospital likely has specific consent forms to use. Ask your supervising physician if you're not sure where to get one.
• Some journals also have their own consent form. Check your target journal's author or submission information to make sure. [5] X Research source

How is a case study report structured?

• Even though the introduction is the first part of a case study report, doctors typically write it last. You'll have a better idea of how to introduce your case study to readers after you've written it.
• Your abstract comes at the top, before the introduction, and provides a brief summary of the entire report. Unless your case study is published in an open-access journal, the abstract is the only part of the article many readers will see.

• Many journals offer templates and checklists you can use to make sure your case study includes everything necessary and is formatted properly—take advantage of these! Some journals, such as BMJ Case Reports , require all case studies submitted to use their templates.

Drafting Your Medical Case Study Report

• Patient description
• Chronological case history
• Physical exam results
• Results of any pathological tests, imaging, or other investigations
• Treatment plan
• Expected outcome of treatment
• Actual outcome of treatment

• Why the patient sought medical help (you can even use their own words)
• Important information that helped you settle on your diagnosis
• The results of your clinical examination, including diagnostic tests and their results, along with any helpful images
• A description of the treatment plan
• The outcome, including how and why treatment ended and how long the patient was under your care [11] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

• You will need references to back up symptoms of the condition, common treatment, and the expected outcome of that common treatment.
• Use your research to paint a picture of the usual case of a patient with a similar condition—it'll help you show how unusual and different your patient's case is.
• Generally, aim for around 20 references—no fewer than 15, but no more than 25. [13] X Trustworthy Source PubMed Central Journal archive from the U.S. National Institutes of Health Go to source

• Close your discussion section with a summary of the lessons learned from the case and why it's significant to consider when treating similar cases in the future.
• Outline any open questions that remain. You might also provide suggestions for future research.

• In your conclusion, you might also give suggestions or recommendations to readers based on what you learned as a result of the case.
• Some journals don't want a separate conclusion section. If that's the case for one of your target journals, just move this paragraph to the end of your discussion section.

Polishing Your Report for Submission to Publishers

• Most titles are fewer than 10 words long and include the name of the disease or condition treated.
• You might also include the treatment used and whether the outcome was successful. When deciding what to include, think about the reason you wrote the case study in the first place and why you think it's important for other clinicians to read.

• Made a significant intellectual contribution to the case study report
• Was involved in the medical care of the patient reported
• Can explain and defend the data presented in the report
• Has approved the final manuscript before submission for publication

• Keep in mind that the abstract is not just going to be the first thing people read—it will often be the only thing people read. Make sure that if someone is going to walk away having only read the abstract, they'll still get the same message they would have if they read the whole thing.
• There are 2 basic types of abstract: narrative and structured. A narrative abstract is a single paragraph written in narrative prose. A structured abstract includes headings that correspond with the sections of the paper, then a brief summary of each section. Use the format preferred by your target journal.

• Look for keywords that are relevant to your field or sub-field and directly related to the content of your article, such as the name of the condition or specific treatments you used.
• Most journals allow 4-8 keywords but check the submission guidelines of your target journal to make sure.

• Blur out the patient's face as well as any tattoos, birthmarks, or unrelated scars that are visible in diagnostic images.

• It's common to thank the patient, but that's up to you. Even if you don't, include a statement indicating that you have the patient's written, informed consent to publish the information.
• Read the journal's submission guidelines for a definition of what that journal considers a conflict of interest. They're generally the same, but some might be stricter than others. [22] X Research source

• If you're not familiar with the citation style used by your target journal, check online for a guide. There might also be one available at your hospital or medical school library.
• Medical librarians can also help with citation style and references if you run into something tricky—don't just wing it! Correct citation style insures that readers can access the materials you cite.

• It's also a good idea to get a beta reader who isn't a medical professional. Their comments can help you figure out where you need to clarify your points.
• Read a lot of case studies published in your target journals—it will help you internalize the tone and style that journal is looking for.

Submitting Your Report to Publishers

• Look into the background and reputation of journals before you decide to submit to them. Only seek publication from reputable journals in which articles go through a peer-review process.
• Find out what publishing fees the journals charge. Keep in mind that open-access journals tend to charge higher publishing fees. [26] X Research source
• Read each journal's submission and editorial guidelines carefully. They'll tell you exactly how to format your case study, how long each section should be, and what citation style to use. [27] X Research source
• For electronic journals that only publish case reports, try BMJ Case Reports , Journal of Medical Case Reports , or Radiology Case Reports .

• If your manuscript isn't suitable for the journal you submitted to, the journal might offer to forward it to an associated journal where it would be a better fit.
• When your manuscript is provisionally accepted, the journal will send it to other doctors for evaluation under the peer-review process.
• Most medical journals don't accept simultaneous submissions, meaning you'll have to submit to your first choice, wait for their decision, then move to the next journal on the list if they don't bite.

• Along with your revised manuscript, include a letter with your response to each of the reviewer's comments. Where you made revisions, add page numbers to indicate where the revisions are that address that reviewer's comments.
• Sometimes, doctors involved in the peer review process will indicate that the journal should reject the manuscript. If that's the case, you'll get a letter explaining why your case study report won't be published and you're free to submit it elsewhere.

• Some journals require you to have your article professionally copy-edited at your own cost while others do this in-house. The editors will let you know what you're responsible for.

• With your acceptance letter, you'll get instructions on how to make payment and how much you owe. Take note of the deadline and make sure you pay it as soon as possible to avoid publication delays.
• Some journals will publish for free, with an "open-access option" that allows you to pay a fee only if you want open access to your article. [32] X Research source

• Through the publishing agreement, you assign your copyright in the article to the journal. This allows the journal to legally publish your work. That assignment can be exclusive or non-exclusive and may only last for a specific term. Read these details carefully!
• If you published an open-access article, you don't assign the copyright to the publisher. The publishing agreement merely gives the journal the right to publish the "Version of Record." [33] X Research source

How do I find a suitable case for a report?

• A rare disease, or unusual presentation of any disease
• An unusual combination of diseases or conditions
• A difficult or inconclusive diagnosis
• Unexpected developments or responses to treatment
• Personal impact
• Observations that shed new light on the patient's disease or condition

• There might be other members of your medical team that want to help with writing. If so, use one of these brainstorming sessions to divvy up writing responsibilities in a way that makes the most sense given your relative skills and experience.
• Senior doctors might also be able to name some journals that would potentially publish your case study. [36] X Research source

Expert Q&A

You Might Also Like

• ↑ https://www.elsevier.com/connect/authors-update/the-dos-and-donts-of-writing-and-publishing-case-reports
• ↑ https://www.bmj.com/content/350/bmj.h2693
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686928/
• ↑ https://health.usf.edu/medicine/internalmedicine/im-impact/~/media/B3A3421F4C144FA090AE965C21791A3C.ashx
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476221/
• ↑ https://www.springer.com/gp/authors-editors/authorandreviewertutorials/writing-a-journal-manuscript/title-abstract-and-keywords/10285522
• ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597880/
• ↑ https://thelancet.com/pb/assets/raw/Lancet/authors/tl-info-for-authors.pdf
• ↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/s13256-017-1351-y
• ↑ https://guides.himmelfarb.gwu.edu/casereports
• ↑ https://casereports.bmj.com/pages/authors/
• ↑ https://jmedicalcasereports.biomedcentral.com/articles/10.1186/1752-1947-7-239
• ↑ https://research.chm.msu.edu/students-residents/writing-a-case-report
• ↑ https://authorservices.taylorandfrancis.com/publishing-your-research/moving-through-production/copyright-for-journal-authors/#

About This Article

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The content of this article is not intended to be a substitute for professional medical advice, examination, diagnosis, or treatment. You should always contact your doctor or other qualified healthcare professional before starting, changing, or stopping any kind of health treatment.

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To start a medical case study report, first choose a title that clearly reflects the contents of the report. You’ll also need to list any participating authors and develop a list of keywords, as well as an abstract summarizing the report. Your report will need to include an introduction summarizing the context of the report, as well as a detailed presentation of the case. Don’t forget to include a thorough citation list and acknowledgements of anyone else who participated in the study. For more tips from our Medical co-author, including how to get your case study report published, keep reading! Did this summary help you? Yes No

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Guidelines To Writing A Clinical Case Report

What is a clinical case report.

A case report is a detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports usually describe an unusual or novel occurrence and as such, remain one of the cornerstones of medical progress and provide many new ideas in medicine. Some reports contain an extensive review of the relevant literature on the topic. The case report is a rapid short communication between busy clinicians who may not have time or resources to conduct large scale research.

WHAT ARE THE REASONS FOR PUBLISHING A CASE REPORT?

The most common reasons for publishing a case are the following: 1) an unexpected association between diseases or symptoms; 2) an unexpected event in the course observing or treating a patient; 3) findings that shed new light on the possible pathogenesis of a disease or an adverse effect; 4) unique or rare features of a disease; 5) unique therapeutic approaches; variation of anatomical structures.

Most journals publish case reports that deal with one or more of the following:

• Unusual observations
• Adverse response to therapies
• Unusual combination of conditions leading to confusion
• Illustration of a new theory
• Question regarding a current theory
• Personal impact.

STRUCTURE OF A CASE REPORT[ 1 , 2 ]

Different journals have slightly different formats for case reports. It is always a good idea to read some of the target jiurnals case reports to get a general idea of the sequence and format.

In general, all case reports include the following components: an abstract, an introduction, a case, and a discussion. Some journals might require literature review.

The abstract should summarize the case, the problem it addresses, and the message it conveys. Abstracts of case studies are usually very short, preferably not more than 150 words.

Introduction

The introduction gives a brief overview of the problem that the case addresses, citing relevant literature where necessary. The introduction generally ends with a single sentence describing the patient and the basic condition that he or she is suffering from.

This section provides the details of the case in the following order:

• Patient description
• Case history
• Physical examination results
• Results of pathological tests and other investigations
• Treatment plan
• Expected outcome of the treatment plan
• Actual outcome.

The author should ensure that all the relevant details are included and unnecessary ones excluded.

This is the most important part of the case report; the part that will convince the journal that the case is publication worthy. This section should start by expanding on what has been said in the introduction, focusing on why the case is noteworthy and the problem that it addresses.

This is followed by a summary of the existing literature on the topic. (If the journal specifies a separate section on literature review, it should be added before the Discussion). This part describes the existing theories and research findings on the key issue in the patient's condition. The review should narrow down to the source of confusion or the main challenge in the case.

Finally, the case report should be connected to the existing literature, mentioning the message that the case conveys. The author should explain whether this corroborates with or detracts from current beliefs about the problem and how this evidence can add value to future clinical practice.

A case report ends with a conclusion or with summary points, depending on the journal's specified format. This section should briefly give readers the key points covered in the case report. Here, the author can give suggestions and recommendations to clinicians, teachers, or researchers. Some journals do not want a separate section for the conclusion: it can then be the concluding paragraph of the Discussion section.

Notes on patient consent

Informed consent in an ethical requirement for most studies involving humans, so before you start writing your case report, take a written consent from the patient as all journals require that you provide it at the time of manuscript submission. In case the patient is a minor, parental consent is required. For adults who are unable to consent to investigation or treatment, consent of closest family members is required.

Patient anonymity is also an important requirement. Remember not to disclose any information that might reveal the identity of the patient. You need to be particularly careful with pictures, and ensure that pictures of the affected area do not reveal the identity of the patient.

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Writing a Case Report

This page is intended for medical students, residents or others who do not have much experience with case reports, but are planning on writing one.  

What is a case report?  A medical case report, also known as a case study, is a detailed description of a clinical encounter with a patient.  The most important aspect of a case report, i.e. the reason you would go to the trouble of writing one, is that the case is sufficiently unique, rare or interesting such that other medical professionals will learn something from it.   

Case reports are commonly of the following categories :

- Rare diseases

- Unusual presentation of disease

- Unexpected events

- Unusual combination of diseases or conditions

- Difficult or inconclusive diagnosis

- Treatment or management challenges

- Personal impact

- Observations that shed new light on a disease or condition

- Anatomical variations

It is important that you recognize what is unique or interesting about your case, and this must be described clearly in the case report.

Case reports generally take the format of :

1. Background

2. Case presentation

3. Observations and investigation

4. Diagnosis

5. Treatment

7. Discussion

Does a case report require IRB approval?

Case reports typically discuss a single patient. If this is true for your case report, then it most likely does not require IRB approval because it not considered research.    If you have more than one patient, your study could qualify as a Case Series, which would require IRB review.  If you have questions, you chould check your local IRB's guidelines on reviewing case reports.

Are there other rules for writing a case report?

First, you will be collecting protected health information, thus HIPAA applies to case reports.   Spectrum Health has created a very helpful guidance document for case reports, which you can see here:   Case Report Guidance - Spectrum Health

While this guidance document was created by Spectrum Health, the rules and regulations outlined could apply to any case report.  This includes answering questions like: Do I need written HIPAA authorization to publish a case report?  When do I need IRB review of a case report?  What qualifies as a patient identifier?

How do I get started?

1. We STRONGLY encourage you to consult the CARE Guidelines, which provide guidance on writing case reports -  https://www.care-statement.org/

Specifically, the checklist -  https://www.care-statement.org/checklist  - which explains exactly the information you should collect and include in your case report.  

2. Identify a case.  If you are a medical student, you may not yet have the clinical expertise to determine if a specific case is worth writing up.  If so, you must seek the help of a clinician.  It is common for students to ask attendings or residents if they have any interesting cases that can be used for a case report. 

3. Select a journal or two to which you think you will submit the case report.   Journals often have specific requirements for publishing case reports, which could include a requirement for informed consent, a letter or statement from the IRB and other things.  Journals may also charge publication fees (see Is it free to publish? below)   

4. Obtain informed consent from the patient (see " Do I have to obtain informed consent from the patient? " below).  Journals may have their own informed consent form that they would like you to use, so please look for this when selecting a journal.

Once you've identified the case, selected an appropriate journal(s), and considered informed consent, you can collect the required information to write the case report.

How do I write a case report?

Once you identify a case and have learned what information to include in the case report, try to find a previously published case report.  Finding published case reports in a similar field will provide examples to guide you through the process of writing a case report.    

One journal you can consult is BMJ Case Reports .  MSU has a multi-year open access publishing agreement with the publisher BM J , and an institutional fellowship with BMJ Case Reports which allows MSU faculty, staff and students to publish in this journal for free.  See this page for a link to the journal and more information on publishing-    https://lib.msu.edu/collections/scholcomm/support

There are numerous other journals where you can find published case reports to help guide you in your writing. 

Do I have to obtain informed consent from the patient?

The CARE guidelines recommend obtaining informed consent from patients for all case reports.  Our recommendation is to obtain informed consent from the patient.  Although not technically required, especially if the case report does not include any identifying information, some journals require informed consent for all case reports before publishing.  The CARE guidelines recommend obtaining informed consent AND the patient's perspective on the treatment/outcome (if possible).  Please consider this as well.  

If required, it is recommended you obtain informed consent before the case report is written.

An example of a case report consent form can be found on the BMJ Case Reports website, which you can access via the MSU library page -  https://casereports.bmj.com/ .  Go to "Instructions for Authors" and then "Patient Consent" to find the consent form they use.  You can create a similar form to obtain consent from your patient.  If you have identified a journal already, please consult their requirements and determine if they have a specific consent form they would like you to use.

Seek feedback

Once you have written a draft of the case report, you should seek feedback on your writing, from experts in the field if possible, or from those who have written case reports before.   

Selecting a journal

Aside from BMJ Case Reports mentioned above, there are many, many journals out there who publish medical case reports.   Ask your mentor if they have a journal they would like to use.  If you need to select on your own, here are some strategies:

1. Do a PubMed search.  https://pubmed.ncbi.nlm.nih.gov/

   a. Do a search for a topic, disease or other feature of your case report 

   b. When the results appear, on the left side of the page is a limiter for "article type".  Case reports are an article type to which you can limit your search results.  If you don't see that option on the left, click "additional filters". 

   c. Review the case reports that come up and see what journals they are published in.

2. Use JANE -  https://jane.biosemantics.org/

3. Check with specialty societies.  Many specialty societies are affiliated with one or more journal, which can be reviewed for ones that match your needs

4. Search through individual publisher journal lists.  Elsevier publishes many different medical research journals, and they have a journal finder, much like JANE  ( https://journalfinder.elsevier.com/ ).  This is exclusive to Elsevier journals.  There are many other publishers of medical journals for review, including Springer, Dove Press, BMJ, BMC, Wiley, Sage, Nature and many others.

Is it free to publish ?

Be aware that it may not be free to publish your case report.  Many journals charge publication fees. Of note, many open access journals charge author fees of thousands of dollars.  Other journals have smaller page charges (i.e. $60 per page), and still others will publish for free, with an "open access option".  It is best practice to check the journal's Info for Authors section or Author Center to determine what the cost is to publish.  MSU-CHM does NOT have funds to support publication costs, so this is an important step if you do not want to pay out of pocket for publishing

*A more thorough discussion on finding a journal, publication costs, predatory journals and other publication-related issues can be found here:   https://research.chm.msu.edu/students-residents/finding-a-journal

Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D. 2013. The CARE guidelines: Consensus-based clinical case reporting guideline development.  Glob Adv Health Med . 2:38-43. doi:  10.7453/gahmj.2013.008

Riley DS, Barber MS, Kienle GS, AronsonJK, von Schoen-Angerer T, Tugwell P, Kiene H, Helfand M, Altman DG, Sox H, Werthmann PG, Moher D, Rison RA, Shamseer L, Koch CA, Sun GH, Hanaway P, Sudak NL, Kaszkin-Bettag M, Carpenter JE, Gagnier JJ. 2017. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol . 89:218-234. doi: 10.1016/j.jclinepi.2017.04.026  

Guidelines to writing a clinical case report. 2017. Heart Views . 18:104-105. doi:  10.4103/1995-705X.217857

Ortega-Loubon C, Culquichicon C, Correa R. The importance of writing and publishing case reports during medical education. 2017. Cureus. 9:e1964. doi:  10.7759/cureus.1964

Writing and publishing a useful and interesting case report. 2019. BMJ Case Reports.  Link to document

Camm CF. Writing an excellent case report: EHJ Case Reports , Case of the Year 2019. 2020. European Heart Jounrnal. 41:1230-1231.  https://doi.org/10.1093/eurheartj/ehaa176  

*content developed by Mark Trottier, PhD

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How to Write an Excellent Clinical Case

JACC: Case Reports aims to serve as a publication vehicle for early career cardiologists and members of the cardiovascular care team, and as a forum for mentorship on the review and publication processes. The last 9 months have been a learning curve for all of us: editors and authors. Publishing is a bilateral learning process: authors learn how to prepare their manuscript, and we as editors aim to provide you with a fruitful feedback on how to make the best presentation of your clinical case. It is very inspiring to see young colleagues—sometimes even medical students—preparing a great manuscript with diligence. It is your work, your efforts, and your time, and we acknowledge every single detail of this manuscript. That is why 2 of the huge responsibilities for me as Editor-in-Chief but also for the Editorial Board are to review the manuscripts thoroughly which will be published and to promote their authors accordingly.

A constant topic of discussion within our Editorial Board meetings is determining what makes a good clinical case and how we can provide the proper feedback to the authors. Through this Editor’s Corner, I selected the top 15 tips for authors, plus 1 more:

• 1. Every submission should be reviewed and re-reviewed before submission. Make sure you submit the best version of your work.
• 2. Carefully read the authors’ instructions to decide which type of article is best for your submission.
• 3. Do a literature search before submission. Just because it is new to you, doesn't mean it is new.
• 4. Don’t forget the physical examination: most of the times it will indicate the diagnosis; therefore, vital signs and a detailed physical examination are key components of your clinical case.
• 5. Provide high-quality imaging (figures and/or videos) to support the information within the text.
• 6. If you have multiple figures, create a multipanel central figure.
• 7. With your figures, please use annotations to teach your colleagues through a demonstration of the anatomy and the pathology.
• 8. Videos are crucial when you submit a clinical case: they help us understand your patient better, and it will facilitate peer review.
• 9. Keep your titles simple, clear, and descriptive. Avoid hyperbolic titles, such as “An extremely rare case….”
• 10. Spell out acronyms and abbreviations when you use them for the first time.
• 11. Use terms and abbreviations as they are used worldwide.
• 12. Algorithms and timeline: When you describe a complex case, a timeline of the clinical case or the demonstration of a management algorithm in a figure may help reader comprehension of your manuscript’s main points.
• 13. The Discussion section should be constructive and evidence based. Think of the Discussion section as the bridge between your patient and the clinical guidelines, but even if you didn’t follow the guidelines, demonstrate to us why you did so.
• 14. Learning objectives: Highlight 2-3 points on what someone could learn from your case.
• 15. Make sure that your manuscript reads well. Remember that the audience for JACC: Case Reports is across the world and of all levels.

Plus 1 more:

• 16. Finally, revise your manuscript for the English language. If English is not your native language, you may want to ask a colleague to read your submission for grammatical purposes.

When you have the final format of your manuscript, ensure all the authors have read it before submission. Don’t hesitate to ask for advice from your senior colleagues when needed.

A clinical case presentation may be considered as the first step in publishing—together with review articles—however, sometimes it is quite challenging to document clinical practice and evidence. Therefore, we ask you to be very careful with the preparation of your manuscript ( Figure 1 ). Include all of your colleagues who were parts of the clinical care of the patient. Demonstrate teamwork. Educate us.

A Flowchart of a Checklist to Follow When Submitting a Manuscript for Consideration

Finally, if your manuscript doesn’t get accepted, don’t get discouraged. It is a learning process. Once you have time to be reflective, read through the comments of the reviewers and Editors to try to understand their feedback in a constructive manner.

Once again, we are grateful for your positive feedback, and we look forward welcoming you to the family of JACC: Case Reports .