Case Reports

Case Report Format

Case reports typically follow this standard format. Be sure to check out the templates and tools linked in the Online Resources box.

• Title
• Abstract
• Introduction
• Case Presentation
• Discussion
• Conclusion
• References
• Acknowledgements

Case presentation summarization

Include:

• History of Present Illness (HPI)
• Review of Systems (ROS), both positives and negatives
• Key Past Medical History (PMH)
  • Social History (SHx), Family History (FHx), medications
• Key physical exam findings
• Diagnostic studies and interventions
• Key elements from clinical course if deviated from usual treatment, e.g. rationale or thought process

Do not include:

• Personally Identifiable Information (PII)
  • e.g., names of people, medical record identifiers, addresses
• Potential identifiers, e.g., abbreviations or initials
  • De-identified information is crucial; use pseudonyms or unrelated identifiers such as Mr. X 

Figures & Tables

• Recommend limiting to one table and three figures [consult publication author guidelines for formal guidance]
•  Used to reveal chronological findings or to compare observations using different methods

Luciano G, Jobbins K, Rosenblum M. A Curriculum to Teach Learners How to Develop and Present a Case Report. MedEdPORTAL. 2018;14:10692. https://doi.org/10.15766/mep_2374-8265.10692

Moore K. A Medical Writing Curriculum for Internal Medicine Residents: Using Adult Learning Theory to Teach Formal Medical Writing and Publication of Case Reports. MedEdPORTAL. 2015;11:10073. https://doi.org/10.15766/mep_2374-8265.10073

Sun Z. (2013). Tips for writing a case report for the novice author. Journal of medical radiation sciences, 60(3), 108–113. https://doi.org/10.1002/jmrs.18 

Backwards Approach

Despite standard formatting, case reports are often easiest to write using the "backwards approach," writing the easiest sections first. For example:

1. Case presentation
2. Discussion
3. Introduction
4. Conclusion
5. Abstract
6. Title
7. References

1. Case Presentation

• Describe events in chronologic order using past tense
  • Describe the response to treatment and state the outcome of the case
• Use standard medical History and Presentation (H&P) formatting
• Avoid abbreviations; for medical terminology, be sure to use the full term followed by the abbreviation in parentheses, then use the abbreviation moving forward
• Be specific and objective
• Include units for all numerical values and list normal values in parentheses for non-standard laboratory tests

2. Discussion

• Most important section; summarizes and interprets the key findings
• Address why your case is unique and significant
• Compare and contrast to other similar reported cases in the literature
  • This is NOT an exhaustive literature review as seen in longer articles for original research or reviews
• If there is another possible differential diagnosis, discuss why it is less likely
• Discuss any recommendations or takeaways you have for practitioners

3. Introduction

• Use present tense
• Orient the reader and provide brief background without giving everything away
• Consider the funnel approach to guide from wider to narrower context 
  • Importance and magnitude of the problem
  • Knowledge gaps and why this case is novel/unique
  • Why this case is valuable

4. Conclusion

• Address takeaways
• Suggest directions for future study, if any

5. Abstract

• Always easiest to write last
• Pay attention to your chosen publication or conference guidelines, particularly in terms of word count

6. Title

• Be specific:
  • Name the disease, condition, or problem
  • Name the population
  • State why it is novel, rare, or unique
• Be careful not to give everything away
• Avoid redundancies such as "case report"

Moore K. A Medical Writing Curriculum for Internal Medicine Residents: Using Adult Learning Theory to Teach Formal Medical Writing and Publication of Case Reports. MedEdPORTAL. 2015;11:10073. https://doi.org/10.15766/mep_2374-8265.10073

Sun Z. (2013). Tips for writing a case report for the novice author. Journal of medical radiation sciences, 60(3), 108–113. https://doi.org/10.1002/jmrs.18 

General Writing

Templates