How to Write Your First Case Report as a Medical Student

To write your first case report as a medical student, identify a case with a clear educational message, involve a clinical supervisor early, obtain written patient consent, organise the clinical events into a timeline, follow the CARE reporting checklist, and tailor the manuscript to a suitable journal. A successful case report is not simply about a rare diagnosis; it explains why the case matters and what clinicians can learn from it.

Written by Dr. Haiqa Afzal for drhaiqaafzal.com.

What Is a Medical Case Report?

A medical case report is a detailed account of the presentation, assessment, diagnosis, treatment, follow-up, and clinical lessons arising from one patient or a small number of closely related patients. It is one of the most accessible forms of academic medical writing for students because it usually begins with a case encountered during a clinical rotation.

Case reports occupy a lower position in the traditional hierarchy of clinical evidence than controlled studies. However, they remain useful for describing unusual presentations, unexpected adverse effects, diagnostic challenges, novel clinical observations, treatment complications, and practical lessons that may help other clinicians.

The strongest case reports answer a focused question: what does this case teach that is not already obvious from a standard textbook description?

Why Medical Students Should Write Case Reports

Writing a case report can help a medical student develop several transferable skills:

• Reviewing medical records systematically
• Constructing a differential diagnosis
• Searching and evaluating medical literature
• Writing clearly and concisely
• Understanding publication ethics
• Working with supervisors and co-authors
• Responding professionally to peer review

A completed report may also strengthen a medical CV, but publication should not be treated as the only goal. The deeper value lies in learning how to convert a clinical observation into a transparent, evidence-aware academic manuscript.

How to Choose a Case Worth Reporting

A case does not need to involve an extremely rare disease. A familiar condition may still be publishable if it contains an unusual presentation, unexpected complication, important diagnostic pitfall, distinctive imaging finding, treatment challenge, or valuable patient perspective.

Features of a potentially publishable case

• An unusual presentation of a common disease
• A rare disease with a clear educational lesson
• An unexpected response or adverse reaction to treatment
• A diagnostic error or delay that teaches a broader lesson
• A previously underreported association between conditions
• A novel clinical, laboratory, pathological, or imaging finding
• A management decision that required careful reasoning
• A public health, ethical, or systems-based lesson

Questions to ask before starting

• What is the main learning point?
• Can the message be explained in one or two sentences?
• Has a similar case already been published many times?
• Are the records, investigations, images, and follow-up available?
• Can informed consent for publication be obtained?
• Is a suitable supervisor willing to guide the work?

Discuss the case with the treating consultant or another experienced clinician before investing substantial time. A supervisor can help assess novelty, clinical accuracy, patient confidentiality, authorship, and journal suitability.

Search the Literature Before Writing

A preliminary literature search helps determine whether the case is sufficiently distinctive and identifies the scientific context for the discussion. Search databases such as PubMed using the diagnosis, unusual feature, intervention, complication, and the phrase “case report.”

For example, a search strategy might combine:

• The main diagnosis
• The unusual presentation or complication
• The intervention or diagnostic test
• Relevant synonyms and medical subject headings

Read recent reports, reviews, and relevant guidelines. Record the full citation details as you work instead of trying to reconstruct the reference list at the end.

Your literature review should answer three questions:

1. What is already known?
2. How is this case similar to or different from previous reports?
3. What practical lesson does this case add?

Obtain Patient Consent and Protect Confidentiality

Patient privacy is central to case-report publication. Written informed consent for publication should normally be obtained before submission, using the form required by the target journal whenever possible.

The International Committee of Medical Journal Editors states that identifying information should not be published unless it is scientifically essential and the patient, parent, or guardian has provided written informed consent. An identifiable patient should also be given an opportunity to review the material intended for publication.

Remove unnecessary identifiers

Do not include names, initials, hospital numbers, complete addresses, exact dates, or other details that could reveal identity unless they are essential and specifically consented to. Simply changing or inventing details is not an acceptable method of anonymisation because it may make the report inaccurate.

Clinical images must also be reviewed carefully. Faces, tattoos, labels, scan identifiers, wristbands, and embedded metadata may reveal identity.

Check local institutional requirements

Case reports are often treated differently from formal research studies, but institutional policies vary. Some hospitals require departmental approval, a privacy review, or confirmation from an ethics committee. Check the policy of the hospital, university, and target journal rather than assuming that no review is required.

Decide Authorship Early

Discuss authorship before drafting begins. Agree on each contributor’s responsibilities, likely author order, corresponding author, and submission duties.

Authorship should reflect meaningful intellectual contribution, participation in drafting or revising the manuscript, approval of the final version, and accountability for the work. A person should not be listed as an author solely because of seniority, departmental position, or routine involvement in the patient’s care.

Medical students commonly serve as first author when they identify the case, conduct the literature review, prepare the first draft, coordinate revisions, and remain actively involved throughout submission.

Follow the CARE Guidelines

The CARE guidelines were developed to improve the accuracy, transparency, and usefulness of clinical case reports. Their checklist provides a practical structure for planning and reviewing your manuscript.

The main CARE elements include:

• Title
• Keywords
• Abstract
• Introduction
• Patient information
• Clinical findings
• Timeline
• Diagnostic assessment
• Therapeutic intervention
• Follow-up and outcomes
• Discussion
• Patient perspective, when appropriate
• Informed consent

Download the CARE checklist at the beginning of the project and use it again before submission. Do not wait until the manuscript is finished to discover that important clinical information is missing.

Build a Clinical Timeline First

Before writing full paragraphs, arrange the case chronologically. A timeline prevents contradictions and makes it easier to identify missing information.

Verify the timeline against the medical record rather than relying on memory. Ask your supervisor to confirm the clinical interpretation.

How to Write Each Section of the Case Report

Title

The title should identify the diagnosis or intervention of interest and usually include the words “case report.” Keep it specific without revealing unnecessary patient information.

A useful format is:

Unusual manifestation or clinical problem in a patient with a defined condition: a case report

Abstract

The abstract should briefly explain the background, central case details, and main conclusion. Follow the exact format and word limit required by the journal. Some journals use a structured abstract, while others require a single paragraph.

Do not introduce claims in the abstract that are not explained in the manuscript.

Keywords

Select terms that accurately represent the diagnosis, presentation, intervention, and educational theme. Include “case report” when required by the journal or CARE checklist.

Introduction

The introduction should be brief. Explain the clinical context, why the case deserves attention, and the specific educational issue it addresses. One to three short paragraphs are usually sufficient.

Avoid turning the introduction into a complete review of the disease.

Patient information

Describe relevant de-identified details such as age range, sex when clinically relevant, presenting concerns, medical history, medication history, family history, psychosocial context, and previous interventions.

Include only information that contributes to understanding the case.

Clinical findings

Report the important examination findings objectively. Separate findings that were present from those that were absent but clinically relevant.

For example, if the differential diagnosis depended on the absence of fever, neurological deficits, haemodynamic instability, or peritoneal signs, state this clearly.

Diagnostic assessment

Explain the investigations, differential diagnoses, diagnostic challenges, and reasoning that led to the final diagnosis. Include relevant laboratory values with units and reference ranges where helpful.

Do not list every test performed. Emphasise investigations that changed the diagnosis or management.

Therapeutic intervention

Describe the treatment precisely, including medication names, doses, routes, frequency, duration, procedures, surgical techniques, and changes in management. Explain why major decisions were made when this forms part of the learning point.

Follow-up and outcomes

Report what happened after treatment. Include objective outcomes, adverse events, adherence, recurrence, repeat investigations, functional recovery, and the duration of follow-up.

A report that ends immediately after diagnosis or intervention may feel incomplete unless the absence of longer follow-up is acknowledged as a limitation.

Discussion

The discussion should interpret the case rather than repeat it. A practical structure is:

1. Restate the central clinical lesson.
2. Compare the case with relevant published literature.
3. Explain plausible mechanisms or diagnostic reasoning.
4. Discuss alternative explanations and limitations.
5. Describe implications for clinical practice.

Avoid claiming that a single case proves causation, treatment effectiveness, or generalisable clinical superiority. Use cautious language such as “suggests,” “illustrates,” or “raises the possibility” when the evidence is limited.

Learning points or conclusion

End with two to four specific messages that a clinician could apply in practice. Strong learning points are concise and directly supported by the case.

Avoid vague statements such as “clinicians should remain vigilant.” Explain exactly what clinicians should recognise, consider, investigate, or avoid.

Patient perspective

Some journals encourage a short account written in the patient’s own words. This can add valuable information about symptoms, communication, treatment burden, recovery, and the experience of navigating healthcare.

Consent statement

Include the journal’s required statement confirming that informed consent for publication was obtained. Do not upload the signed consent form unless the journal specifically requests it through a secure submission process.

Write Clearly and Clinically

Good case-report writing is precise, chronological, and restrained. Use standard clinical terminology, but avoid unnecessary complexity.

Practical writing principles

• Use short, direct sentences.
• Present events in chronological order.
• Define abbreviations at first use.
• Use consistent units and terminology.
• Separate observations from interpretations.
• Report negative findings only when clinically relevant.
• Avoid unsupported claims of novelty.
• Do not copy wording from published reports.

When describing novelty, it is safer to write that few comparable reports were identified in your search rather than claiming that the case is the first ever reported.

Choose the Journal Before Finalising the Draft

Journal selection affects word count, headings, reference style, image requirements, consent documentation, publication fees, and article structure. Review the journal’s author instructions before completing the manuscript.

Evaluate a journal carefully

• Does the journal publish case reports in this specialty?
• Is the case relevant to its readership?
• Is the journal indexed in recognised bibliographic databases?
• Are publication or article-processing charges clearly stated?
• Does the website provide transparent peer-review and editorial policies?
• Does the journal require institutional membership or a fellowship?
• Are consent, authorship, and conflict-of-interest requirements clear?

Be cautious of journals that guarantee acceptance, advertise extremely rapid publication without credible review, use misleading metrics, or send persistent unsolicited invitations.

Prepare Figures, Tables and Clinical Images

Use a figure or table only when it improves understanding. Common examples include radiological images, histopathology, operative findings, electrocardiograms, clinical photographs, laboratory trends, and timelines.

Each figure should have:

• A clear legend
• Labels or arrows where necessary
• Adequate resolution
• Removal of patient identifiers
• Permission for any previously published material

Do not manipulate images in a way that changes their clinical meaning. Global adjustments to brightness or contrast may be acceptable under some journal policies, but selective alteration of findings is not.

Common Mistakes in a First Case Report

• Starting without confirming consent
• Choosing a case with no clear learning point
• Writing before checking the target journal
• Including too much routine clinical detail
• Failing to explain the differential diagnosis
• Repeating the case history in the discussion
• Claiming causation from one patient
• Overstating rarity or novelty
• Using outdated or irrelevant references
• Ignoring missing follow-up information
• Submitting without senior clinical review
• Listing honorary authors

A Step-by-Step Workflow for Medical Students

1. Identify the educational message. Write the main lesson in one sentence.
2. Approach a supervisor. Confirm clinical relevance, feasibility, authorship, and responsibilities.
3. Check consent and institutional requirements. Complete these before sharing identifiable information.
4. Search the literature. Determine what has already been reported.
5. Select a target journal. Review its scope, format, fees, and policies.
6. Collect verified case information. Use the clinical record, investigation reports, and follow-up documentation.
7. Create the timeline. Organise the sequence of symptoms, investigations, diagnosis, treatment, and outcomes.
8. Draft the case presentation. Write the factual clinical narrative first.
9. Write the discussion. Compare the case with the literature and explain its lesson.
10. Complete the abstract, title, conclusion, and learning points.
11. Check the CARE checklist. Address every applicable item.
12. Ask all authors to review the final version.
13. Submit and respond to reviewers carefully.

How to Respond to Peer Review

Reviewer comments are a normal part of publishing. Read the decision letter carefully, discuss major points with your supervisor, and prepare a point-by-point response.

For each comment:

1. Quote or summarise the reviewer’s point.
2. State what you changed.
3. Identify where the change appears in the revised manuscript.
4. Explain respectfully when you disagree.

Do not respond defensively. Even when a suggested change is not adopted, acknowledge the concern and provide a clear academic justification.

Final Submission Checklist

• The case has a clear, clinically relevant learning point.
• Written consent for publication has been obtained.
• Institutional requirements have been checked.
• All unnecessary identifiers have been removed.
• Authorship and author order have been agreed.
• The manuscript follows the target journal’s instructions.
• The CARE checklist has been completed.
• Clinical facts, dates, units, and references have been verified.
• Figures are anonymised, labelled, and high resolution.
• Conflicts of interest and funding are disclosed.
• All authors have approved the submitted version.

Final Thoughts

Your first case report should focus on one defensible clinical message. Start with verified patient information, protect confidentiality, obtain consent, follow the CARE structure, and work closely with an experienced supervisor. A carefully written report can turn a single clinical encounter into a useful lesson for other healthcare professionals while giving you a practical introduction to medical publishing.