A case report is often the first piece of medical writing a student can genuinely call their own: one patient, one puzzle, and a lesson other clinicians can use. It is also a genre with rules. Journals follow the CARE checklist, examiners expect a recognisable shape, and patients are protected by consent and anonymisation requirements that are not decorative. This guide walks through the whole process — choosing a case worth reporting, securing consent, working through every CARE section, and writing a discussion that earns its place against the published literature. For the broader demands of medical coursework, see our medicine assignment help pages.
Case reports sit at the start of the evidence hierarchy, and that is their strength rather than a weakness. A single well-observed case can flag a rare presentation, an unexpected adverse effect, or a diagnostic trap long before any trial exists. Your job as the writer is to make that one case trustworthy: complete, honestly limited, and impossible to confuse with the patient it came from.
Coursework case reports are not journal submissions — but they borrow the same skeleton
Many students meet case reports first as coursework: a placement write-up, an SSC submission, or a portfolio case. Those differ from journal articles in audience and stakes — no peer reviewers, no publication fees, no indexing — but markers borrow the journal standard because it is the professional standard. A coursework report that follows CARE, anonymises properly and discusses the case against real literature reads as the work of a future doctor; one that narrates a patient’s admission like a ward-round story does not.
The practical differences are worth knowing. Coursework briefs set their own word limits and may ask for extras a journal would not — a reflection, a guideline audit, or teaching points for peers. Journals, by contrast, impose their own consent forms, reference styles and article types, and many established titles accept case reports rarely or not at all, leaving dedicated case report journals as the usual route. If there is any chance your coursework case might later be developed for submission, write it to CARE from the start and keep the consent paperwork; retrofitting either is painful.
Choosing a case that deserves reporting
Not every interesting patient makes a reportable case. The recognised categories are consistent across the guidance: a rare condition; a common condition presenting unusually; an unexpected event or adverse outcome; a difficult or initially missed diagnosis; a management dilemma where the standard approach did not fit; or an observation that sheds new light on something familiar. Interesting to you is not the test — every patient on your first firm is interesting. The test is whether a clinician who never met this patient would learn something transferable.
Two conversations come before any writing. First, talk to the consultant or senior responsible for the patient’s care: they will know whether the case is genuinely unusual, whether someone else is already writing it up, and whether the learning point you have spotted is the right one. Second, search the literature early. If the supposedly rare presentation has forty published reports, your case needs a different angle or a different case. That search is not a chore bolted onto the end; it is how you find out what your report is actually about.
Consent and anonymisation: the non-negotiables
Obtain the patient’s informed consent for the report, in writing, using your institution’s or target journal’s form where one exists. Consent is separate from the team’s permission: your consultant agreeing does not substitute for the patient agreeing. Explain what will be written, where it may appear, and that they can decline without any effect on their care. Where a journal requires it, the patient should see the report itself. If the patient has died, consent is sought from the next of kin; if consent genuinely cannot be obtained, follow your institution’s process and document the justification rather than proceeding on optimism.
Anonymisation then does the second half of the work. Remove names, initials, hospital numbers, exact dates and addresses — and then think about jigsaw identification. A rare diagnosis, an unusual occupation, a small town and an approximate age can identify a person in combination even when each detail looks harmless alone. Generalise what the clinical lesson does not need, crop or anonymise images properly (imaging systems can strip identifiers), and store any identifiable working notes only on approved, secure systems. For a student report, one rule covers most situations: if the patient or their family could recognise themselves and would be surprised by anything on the page, you have not finished anonymising or consenting.
The CARE checklist, section by section
CARE — CAse REport — is the consensus reporting guideline for case reports, published in 2013 and listed by the EQUATOR Network. It has thirteen items. Markers and editors use it because a report missing an item usually has a hole where a reader’s question should be answered.
- Title. Name the diagnosis or intervention of primary interest and include the words “case report”. A title should be searchable and honest, not a teaser.
- Keywords. Two to five terms identifying the case’s key elements, including “case report” itself where the format asks.
- Abstract. Written last. It covers what is unique about the case and what it adds, the main symptoms and clinical findings, the principal diagnoses, interventions and outcomes, and the take-away lesson.
- Introduction. One or two paragraphs placing the case: why this condition or presentation matters, how rare or under-recognised it is, and what gap this case speaks to — with references to the literature, not assertion.
- Patient information. De-identified demographics, the patient’s main concerns and symptoms in roughly their terms, relevant medical, family and psychosocial history, and past interventions with their outcomes.
- Clinical findings. The relevant examination and clinical findings — pertinent positives and important negatives, in the order a clinician would want them.
- Timeline. The episode of care as a clear chronology, often best as a small table or figure: presentation, key investigations, diagnosis, intervention, outcome. Timelines expose muddled narratives, which is why CARE insists on one.
- Diagnostic assessment. The methods used (examination, laboratory tests, imaging), the diagnostic reasoning including the differential diagnosis and why alternatives were set aside, any diagnostic challenges such as access or atypical results, and prognostic features where relevant.
- Therapeutic intervention. What was actually done: type of intervention, and its administration in usable detail — drug, dose, route, duration; procedure and who performed it; and any changes made along the way with the reasons for them.
- Follow-up and outcomes. What happened afterwards: clinician-assessed and patient-reported outcomes, follow-up investigations, adherence and tolerability, and adverse events, expected or otherwise. A report without an outcome is a story without an ending.
- Discussion. The case set against the literature — covered in the next section, because it is where reports are won and lost.
- Patient perspective. Where appropriate, the patient’s own view of the experience and treatment, in a paragraph or two. In coursework, include it when the brief and consent allow; its absence should be a decision, not an oversight.
- Informed consent. A closing statement that consent for publication was obtained (or the documented position if it could not be). Editors check this item first; never leave it implicit.
Writing the discussion against the literature
The discussion is not a summary of the case with references attached. Its job is comparison. Open with what your case adds — the point your introduction promised — then place the case beside what has already been published: how did presentation, investigation findings and response to treatment match or diverge from reported cases and current guidelines, and what might explain any divergence? A case that behaves exactly as the literature predicts still teaches, but a case that departs from it teaches more, provided you reason about why rather than merely noting the difference.
Then be honest about limits. A single case cannot establish causation, estimate frequency, or justify changing practice on its own; saying so plainly strengthens rather than weakens the report. Note what information was unavailable, which alternative explanations remain open, and what a clinician should actually take away: a differential not to miss, a question to ask, a test to consider earlier. End on that take-away lesson, stated in terms a reader can act on.
References in Vancouver style
Medical journals most commonly ask for Vancouver referencing: sources numbered in the order they first appear in your text, cited in the text by number, with the reference list in that same numerical order. Two habits keep it clean. Cite as you write, because renumbering a finished report by hand is how errors breed. And keep the list proportionate — the Royal College of Physicians’ guidance offers a rule of thumb that most case reports need no more than about ten references, each one visibly used in the introduction or discussion rather than padding a bibliography. If your school or journal specifies a different style, follow it; if it specifies Vancouver, our Vancouver referencing generator will format entries consistently.
Finally, draft in the order that works, not the order on the page: gather the notes and timeline first, write the case sections while the record is in front of you, then the discussion, then the introduction, and the abstract last of all. If your case arose on an elective or placement abroad, the write-up discipline here pairs naturally with our guide to writing a medical school elective report.
Get support with your case report
If you have the case but not yet the report — a timeline that will not settle, a discussion that keeps collapsing into summary, or CARE sections you are unsure how to pitch — United Academic Help can help. Our medical writing support covers case reports, elective and SSC reports and reflective work from £20 per 1,000 words, with the price agreed before any work begins. Email your brief to team@unitedacademichelp.uk to place an order, or message us on WhatsApp through our contact page and tell us whether the report is for coursework or a journal, and what deadline you are working to.
Frequently asked questions
What is the CARE checklist? CARE is the consensus reporting guideline for case reports, published in 2013. Its thirteen items — title, keywords, abstract, introduction, patient information, clinical findings, timeline, diagnostic assessment, therapeutic intervention, follow-up and outcomes, discussion, patient perspective and informed consent — define what a complete case report contains.
Do I need patient consent for a coursework case report? Treat consent and anonymisation as required unless your institution’s brief explicitly sets a different process for internal coursework. Journals require written informed consent as a condition of publication, and building the habit at coursework stage — consent sought, identifiers removed, jigsaw risk checked — is part of professional training.
How long should a case report be? There is no single length: journals set their own limits and coursework briefs set theirs. Case reports are short by design — the clinical narrative is usually a few hundred words and the discussion carries most of the analysis. Check your brief or target journal rather than aiming at a generic figure.
How many references does a case report need? Fewer than most students expect. Guidance from the Royal College of Physicians suggests around ten as a rule of thumb for journal reports. Every reference should be doing work in the introduction or discussion; a long list the text never uses signals padding, not scholarship.
What makes a case worth reporting? Novelty with a transferable lesson: a rare condition, an unusual presentation of a familiar one, an unexpected event, a difficult diagnosis, or a management problem where standard approaches did not fit. Discuss the case with the responsible consultant and search the literature before deciding — both steps quickly reveal whether the angle is genuinely new.
Can a case report be published by a medical student? Yes. Students publish case reports, usually with a supervising clinician as a co-author, in dedicated case report journals and sometimes as posters or presentations first. Authorship should reflect real contribution and be agreed with the team early; journals typically limit author numbers, so discuss it before you write, not after.