Guidelines to write a case report

blog_15_01_2020A case report is a comprehensive analysis of the symptoms, diagnosis, treatment, and follow-up of an individual patient with a particular disease or ailment. It helps in developing new ways to combat diseases and heal patients. Sometimes case reports act as a powerful source to find solutions for any unknown situation in a patient.

To write a case report, one has to:

  1. Understand the message you want to send across and your audience that you wish to connect with. You have to ask yourself“is this case report a result or a diagnostic assessment or a new or rare disease?”You would get the answer as you analyze it. It is advised to do so before you start writing.
  2. Chart-out a timeline of the case report you are working on to visualize what went on in the case report. You may write it in bullet points or whatever makes you comfortable.
  3. Finish the rest of the case report with specific data that is important with suitable scientific references, even explanations.
  4. Another most important aspect of case report writing is the de-identification of a patient.

How to write a case report in order?

  • Working Title: The title should systematically describe and reflect your work
  • Timeline: As mentioned above, make a timeline of events and put them in chronological order. You may use figures to explain it further.

How to narrate the episode of care?

  • Clinical finding: define the related past medical history and important physical examination findings.
  • Diagnostic assessment: discuss thoroughly the diagnostic tests and results and include differential diagnosis and the diagnosis itself.
  • Therapeutic intervention: define the types of interference and how it was administered such as dosage, strength, duration and frequency.
  • Follow-ups and results: describe the clinical sequence of the period of care during follow-up visits including- involvement, alteration, disruption, or discontinuation and how each of them was accessed. Unnatural or adverse effects and situations should be explained as well.


Coming to the obvious and important aspects of a case report, the introduction should be to the point. It should concisely summarize the reasons why this case report is important. Then write the conclusion of the most important findings from the case you are writing on without any references.

How to write the – Abstract, Key Words, References, Acknowledgement and Informed Consent

Abstract: An abstract in a case report is the brief summary in a structured/unstructured format with significant information and since an abstract is supposed to inform a reader, do not include citations.

Key Words: Provide a few keywords (4-5) that is relevant to the case report and make sure they are not overused in similar case reports and unique. It is okay if it is repeated though.

References: Make sure to include references from peer-reviewed scientific literature.

Acknowledgment: You should ideally include people who support you including funding and institutional support.

Informed Consent: The patient should provide their informed consent, including a patient perspective. The author should provide this information if requested for. Some journals have “consent form” which is mandatory to use regardless of informed consent you have obtained in other forms. Sometimes additional approval from IRB or ethics commission is also required. Last but not the least, the patient should be asked to provide their treatment experience in a paragraph or two. To make it easier, you may write it on their behalf while they share it with you.

Appendices (if indicated):

On must always follow author guidelines of their preferred or approved journal that they want to publish in. This might be a time-consuming task since guidelines vary from journal to journal. It is ideal to contact your journal’s publishing assistant before you proceed with this and submitting your manuscript.

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