How to Write a Case Report

Written by Neha Deo

So you have the opportunity to write a scientific case report - but how do you start? Well, you’ve come to the right place.

First, let’s start with what a case report is. Case reports are a piece of work that describes an individual patient case in the form of a detailed story. Case reports are a unique finding not previously documented. For example, a case report could be a new finding of a pathological disease, like when patients with COVID-19 were revealed to have a loss of taste/smell. Generally, these pieces are anywhere from 700-1000 words long. 

Before starting the case report, your research mentor will likely provide the patient ID number to look them up in the electronic medical record. The first thing to do is to read up on this patient and find the provider notes that are most relevant to the case you are writing about. It’s valuable to look at their lab values, biopsy results, and imaging results from this encounter. I like to write these down on a sheet so I can get my thoughts together.

Next, it’s time to do some background reading on the disease you’re going to be writing about. Databases such as MedLine or PubMed will generate a ton of results related to the disease. This will help your discussion later. 

Let’s talk a little about the outline of the case report. Generally, there is an abstract, introduction, the case report (this is the section that you write about the patient), and discussion. Let’s elaborate on this a little more: 

1. Abstract: This section can be considered like a “blurb” that discusses your project overview. It’s important to be succinct and let readers get a sense of what your case report will be about. This is usually around 100 words long.

2. Introduction: This is where you give an overview of the disease you are going to talk about. Generally, this is similar to an introduction to any paper. Discussion about the pathology, symptoms of the disease, and prevalence goes into this part of the case report. This section is usually 100-200 words long.

3. Case Report: The case report section is an overview of your patient. Here, you discuss the disease course, presentation and symptoms of the patient, and any lab testing that was performed and their results. This section can help set the stage for the discussion. Generally, this section is 200-300 words long.

4. Discussion: This is the meat of your project. A discussion explains how the authors interpret their data and use other cited studies to refute or support their findings. This is an opportunity to talk about other case reports that may have found similar findings to your project. Authors will often discuss the significance of their results and the implications of their findings. This section is usually 250-500 words long.

There you have it! Your research mentors will always be willing to help, so don’t be afraid to ask if you need any clarifications. Good luck!