How to Write a Medical Case Report: Template, Consent & Submission Steps

Patient consent is not a formality; it is a core ethical requirement for publishing a medical case report.

Writing a medical case report is a practical way for students and junior clinicians to publish clinical observations, document rare diseases, and share educational lessons. This guide walks you through every step, from selecting a valuable case and using a proven template to obtaining consent and submitting successfully to a medical journal. You’ll also find a ready-to-use structure, a reference table, and common pitfalls to avoid.

What Is a Medical Case Report?

A medical case report is a detailed account of a single patient’s clinical presentation, diagnosis, treatment, and follow-up. It highlights unusual findings, unexpected responses to treatment, or common conditions presenting in an uncommon way. Case reports are the lowest level of evidence, yet they remain an essential source of new knowledge, especially in rare disease contexts.

• Describes one patient, or occasionally a small case series (two to four cases).
• Includes the patient’s history, physical examination, laboratory results, imaging, pathology, treatment, and outcome.
• Focuses on clinical novelty, educational value, or a hypothesis-generating observation.
• Often written by students, residents, and mid-career physicians as a first step in academic publishing.

Why Write a Medical Case Report?

Publishing a case report helps you learn to search literature critically, reason through a differential diagnosis, and communicate clinical findings clearly. For a student, it can be an impressive addition to a CV and a strong indicator of academic initiative.

• Develops familiarity with manuscript preparation, peer review, and journal submission systems.
• Encourages deep research into a clinical topic and comparison with similar published cases.
• Offers an opportunity to promote patient safety or system improvements in clinical practice.
• May serve as the foundation for a case series, retrospective study, or review article.

The Medical Case Report Template

The most widely accepted reporting standard is the CARE (CAse REport) guideline, which lists the items that should be present in a high-quality medical case report. You will usually structure your manuscript according to journal preferences, but the following template is a safe starting point for most journals.

• Title and keywords: Write a concise title that includes “case report” and the key diagnosis or clinical feature. Add three to five keywords for indexing.
• Abstract: Summarize the background, case presentation, diagnosis, treatment, outcome, and educational lesson in 150–250 words.
• Introduction: Provide a short literature background, explain why the case is unusual or valuable, and state the learning objective.
• Case Presentation: Describe the patient’s demographics, presenting symptoms, relevant medical history, examination, investigations, differential diagnosis, treatment, and long-term follow-up.
• Discussion: Compare your case with previously published reports, discuss diagnostic or therapeutic challenges, acknowledge limitations, and highlight practical lessons.
• Conclusion: End with one or two clear takeaway messages for clinicians.
• Patient perspective: Some journals invite the patient to comment on their experience, though this is optional.
• Consent statement: Include an explicit sentence confirming that written informed consent was obtained from the patient or their legal guardian.
• References: Use the citation style required by the target journal.

Patient Consent and Ethical Requirements

Before you write a single word, you need formal permission from the patient. This is not only a legal requirement in most countries, but also an ethical obligation that protects both the patient and the credibility of your report.

• Obtain written, informed consent from the patient, or from a legal guardian if the patient is a minor or lacks capacity.
• Explain in plain language how the case will be published, where it may appear, and whether images or personal details will be included.
• Remove or anonymize all identifiers: name, birth date, initials, exact address, hospital record number, and any facial images unless strictly necessary.
• Request additional consent if you plan to include radiographic images, histopathology slides, or photographs that might identify the patient.
• Mention the consent statement explicitly in your manuscript: “Written informed consent for publication was obtained from the patient/family.”

A well-written cover letter can make the difference between being sent out for review and being immediately rejected.

How to Submit Your Medical Case Report: Step-by-Step

Submission workflows vary by journal, but most medical journals use online manuscript management systems. The following steps will help you stay organized and reduce the chance of technical rejection.

• Choose a journal that publishes case reports: some have dedicated case report sections, while others are entirely case-report-oriented.
• Read the author guidelines carefully before preparing your files. Pay attention to word limits, reference format, and required sections.
• Write a focused cover letter that explains what is new about your case and why the journal’s readers would benefit.
• Prepare the manuscript in the requested format, usually Microsoft Word or PDF, with line numbers if required.
• Upload figures and tables separately if the journal asks you to do so; provide appropriate titles and captions.
• Fill out the submission forms accurately, including all authors’ details, contributions, conflicts of interest, and funding sources.
• Submit the manuscript and track the status through the portal. Respond to reviewer comments politely and point-by-point.

Common Pitfalls to Avoid in Medical Case Reports

Editors reject many case reports not because the case is not interesting, but because the manuscript is poorly structured or does not follow journal requirements. Knowing common mistakes can save you time and frustration.

• Starting to write before securing patient consent or institutional approval.
• Including identifiable information without explicit consent.
• Using a generic structure that does not conform to the target journal’s author guidelines.
• Providing insufficient case detail, especially about diagnostic workup or follow-up.
• Overstating the novelty of the case without adequate literature comparison.
• Ignoring negative findings, which are often as valuable as positive findings.
• Submitting the same manuscript to multiple journals simultaneously (duplicate submission).
• Failing to disclose a conflict of interest or contributions from other authors.

Writing a medical case report is a structured but rewarding process. Choose a case with a clear educational message, follow a recognized template, obtain proper consent, and select a suitable journal. By doing so, you will contribute a useful clinical observation to the medical literature and start your academic publishing journey.

Frequently Asked Questions about Medical Case Reports

What is the ideal length of a medical case report?

Most case reports range from 1,200 to 1,800 words before references. Some journals accept shorter formats, such as “case letters” or “clinical images,” which may only require 300–500 words. Always check the author guidelines of your target journal.

Can medical students write a case report without a senior author?

It is uncommon and generally not recommended. A supervising clinician or attending physician usually provides clinical context, verifies accuracy, and guides the consent process. Students can certainly lead the writing and submission, but a senior author is expected to review the final manuscript and accept responsibility for its content.

How long does it take to publish a case report?

The timeline varies greatly. After submission, a journal may take several weeks to decide whether to send the manuscript for peer review. Once accepted, publication can happen online within a few weeks or months. Print publication may take additional time. As a rough guide, expect a total timeline of three to nine months from first submission to online publication.

Do I need ethical approval for a case report?

Most journals and institutions do not require full ethical review board approval for a retrospective report of a single patient, but they require written informed consent. However, some institutions have explicit policies that case reports qualify as human subjects research and require IRB exemption or approval. Check with your local research office and the journal.

Not necessarily. A case report can be about a rare disease, an unusual manifestation, an unexpected drug reaction, or a common illness with an atypical treatment path. The key is that the case carries a practical educational message for clinicians.

What if the patient is deceased?

You still need consent for publication, usually from next of kin or the legal representative. Some journals may waive this requirement when the patient cannot be contacted and the information is completely anonymized, but you must state this situation in the manuscript. You should also avoid including details that could identify the deceased patient or their family.

How can I choose a suitable journal for my case report?

Start by listing journals that publish case reports in your specialty. Compare their scope, acceptance rates, peer review duration, and publication fees. Look