How to Write a Medical Case Report

A medical case report describes the clinical course of one patient (or a very small number) in enough detail that other clinicians can learn from it. A good report has a clear take-home message, protects patient privacy, is grounded in the literature and follows a reporting guideline such as CARE.

Step-by-step

1. Choose a case worth reporting (see What Makes a Case Worth Publishing?).
2. Obtain consent for publication and follow local approval rules (see How to Obtain Patient Consent for Case Report Publication).
3. Collect the facts from the record: history, examination, tests, treatment, outcome, with dates.
4. Review the literature so you can state what is new (see How to Perform a Literature Review for a Case Report).
5. Choose a journal and read its case-report instructions.
6. Draft using the CARE structure: title, keywords, abstract, introduction, patient information, clinical findings, timeline, diagnostic assessment, interventions, follow-up and outcomes, discussion, patient perspective and consent.
7. Prepare images with consent and de-identification.
8. Check against the CARE checklist and have a senior clinician review the draft.

Illustrative example

Invented for teaching. A resident reports an adult with fever and a rash after starting a new antibiotic. Her take-home message is that a delayed drug reaction can mimic infection and change management. She describes the timeline (day 0 start, day 8 rash), the tests ruling out infection, the treatment change and recovery, and discusses similar reports she found in PubMed.

Common pitfalls

• A case that adds nothing new or is simply common.
• Identifying details that could reveal the patient.
• A discussion that repeats a textbook without comparing with the literature.
• Overstating causality from a single case.

Key takeaways

• A clear message, consent and CARE reporting are the foundations.
• MRN provides a free case report template that follows the CARE structure.

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.