How to Write a Case Presentation

The case presentation is the factual core of a case report. It tells the patient's story in chronological order, with enough detail for a clinician to understand the reasoning, but without identifying the patient or adding interpretation.

Suggested order (following CARE)

1. Patient information: de-identified demographics, presenting concerns, relevant history.
2. Clinical findings: key examination findings.
3. Timeline: dates or relative times of key events (day 0, day 3).
4. Diagnostic assessment: tests, results, reasoning, differential diagnoses, challenges.
5. Therapeutic intervention: what was given, doses, changes and why.
6. Follow-up and outcomes: how the patient did, adverse events, adherence, patient-reported outcomes.

Writing rules

• Use past tense and a neutral, factual style.
• Report units and reference ranges; use a table for laboratory values.
• Use relative times ("day 8") rather than dates.
• Include relevant negatives (tests that were normal) that rule out alternatives.
• Leave interpretation for the discussion.
• Check every number against the record.

De-identification

Remove names, initials, dates of birth, hospital numbers and any detail that makes the patient identifiable (rare occupations, exact location). Where a detail is clinically important, discuss it with the patient when obtaining consent and follow journal policy.

Illustrative example

Invented for teaching. "A 62-year-old man presented with 3 days of fever (38.9 °C) and a rash on day 8 of oral antibiotic therapy. Examination showed a diffuse maculopapular rash and no lymphadenopathy. Blood cultures were negative; eosinophils were 1.8 × 10⁹/L." (Invented case.)

Using tables and figures

A laboratory table with dates, values and reference ranges is easier to read than a paragraph of numbers. An imaging figure or a clinical photograph can strengthen the report, but needs specific consent and anonymisation (see How to Prepare Clinical Images for a Case Report). A timeline figure, described in How to Create a Clinical Timeline for a Case Report, helps readers follow events without extra text.

Common pitfalls

• Mixing results and opinion.
• Omitting the sequence of events.
• Leaving identifiers in.

Key takeaways

• Chronological, factual, de-identified and complete.
• Use a timeline and tables.

This page is general educational information about research methods. It is not medical, legal or regulatory advice; follow your institution's ethics board and your target journal's instructions.