What a case report is — and is not
A case report describes one patient (occasionally a very small number if the journal uses “case report” broadly) to communicate a clinically meaningful observation. Its value is usually novelty, an unusual presentation, an unexpected adverse effect, a diagnostic lesson, a management challenge, or a useful educational message. It cannot establish incidence, prevalence, comparative effectiveness or causality.
What you need before you start
- A clear one-sentence learning point: “This case matters because…”
- A complete clinical timeline from first presentation through outcome/follow-up.
- Access to relevant notes, investigations, imaging and treatment details through an authorised clinical/research route.
- A literature search showing what is already known and why the case adds something.
- A patient-consent plan and institutional determination about whether a separate research/ethics submission is required.
- A target journal or at least its article type and consent policy before final formatting.
Approval, consent and privacy
Usually needs formal review / authorisation
- Written consent for publication when the patient could be identifiable from text, images, pedigree, rare condition, dates or context; many journals require a specific consent form.
- Authorised access to the medical record and any photographs, imaging or laboratory data.
- Institutional/research-office review if local policy classifies or routes the case through a research, publication or governance process.
May follow a lighter or different route
- A single case report is not classified as human-subject research in some institutions because it is primarily a clinical description rather than a systematic investigation designed to produce generalisable knowledge. That does not remove confidentiality or publication-consent duties.
- Completely non-identifiable educational material may have a different consent route in some settings, but the journal and institution decide this—not the author.
Do not do this
- Do not assume that removing the name makes a case anonymous. Rare diagnoses, exact dates, photographs, occupation, nationality, facility, family structure or distinctive clinical details can re-identify a person.
- Do not use a clinical photograph or identifiable imaging screenshot without the required permission.
- Do not invent, alter or omit clinically important facts merely to make the story more publishable.
Mediclinic Middle East publicly states that research projects carried out at MCME are to receive approval from its internal Research and Ethics Committee and applicable local regulatory authorities before initiation. The exact route varies by project, facility and emirate. Dubai projects may involve DSREC depending on applicability. This hub must therefore route users to the Research Office and current local forms rather than declaring a project “ethics exempt.” Institution-specific forms and contacts will be inserted after verification.
Step-by-step workflow
Confirm that the case has a defensible educational message
Write the proposed take-home message in one sentence. If the message is simply “this disease exists,” the case is unlikely to be strong. Ask what a reader would learn that changes recognition, reasoning, safety or understanding.
Search the literature before drafting
Search the diagnosis, intervention, adverse event or unusual association. Record the most similar published cases and reviews. This establishes novelty and prevents exaggerated claims such as “first ever” without evidence.
Check local publication and consent requirements
Before exporting notes or images, confirm with the authorised office/supervisor whether the case needs ethics/research-office determination, data-release approval, publication approval, or a specific institutional patient consent form.
Obtain publication consent
Use the consent route required by the institution and target journal. The patient should understand that publication may place clinical information on the internet and that absolute anonymity cannot always be guaranteed. Keep the signed consent securely; do not upload it to the manuscript unless the journal specifically requires that route.
Create a de-identified case worksheet
- Age range or exact age only if clinically necessary.
- Presenting concern and duration.
- Relevant past medical/family/social history.
- Examination findings.
- Investigations with units and reference ranges where relevant.
- Differential diagnosis and reasoning.
- Final diagnosis and how it was established.
- Treatment/intervention with dose/timing when relevant.
- Outcome, adverse events and follow-up.
- Patient perspective if appropriate and consented.
Build a timeline
Create a chronological table with dates converted to relative timing when exact calendar dates are not necessary, for example “Day 0,” “Week 3,” and “Month 6.” The timeline prevents contradictions between the history, results and discussion.
Select only necessary images and tables
Use the minimum number needed to teach the point. Remove names, medical-record numbers, dates of birth and other identifiers from screenshots. Confirm that cropping or masking does not distort the scientific meaning.
Draft in CARE structure
- Title: identify the clinical focus and that it is a case report.
- Abstract: uniqueness, core presentation, diagnosis/intervention/outcome and lesson.
- Introduction: why the case is worth reporting.
- Patient information and clinical findings.
- Timeline.
- Diagnostic assessment, including differential diagnosis and challenges.
- Therapeutic intervention.
- Follow-up and outcomes, including adverse events.
- Discussion: compare with literature, explain strengths/limitations and avoid causal overclaiming.
- Patient perspective when appropriate.
- Informed consent statement.
Write the discussion around the learning point
Do not turn the discussion into a broad textbook review. Compare the case with the closest literature, explain what is unusual, give plausible mechanisms only when supported, and state what cannot be concluded from a single patient.
Run a privacy audit
Read the manuscript as if you know the patient. Ask whether combinations of age, dates, location, profession, family details, imaging and rare diagnosis could reveal identity. Remove nonessential detail and reconfirm consent if major content changes.
Complete the CARE checklist and journal requirements
Map each CARE item to the manuscript page/section. Check word count, figure limits, references, declarations, author contributions and the journal’s patient-consent policy.
Submit and archive
Keep the final consent, institutional determination/approval, submitted manuscript, CARE checklist and final accepted version in the study folder. After publication, add the verified citation/DOI to Research Pulse.
Common reasons case reports fail
- No clear novelty or educational message.
- Consent obtained too late or not in the form required by the journal.
- Insufficient follow-up to know the clinical outcome.
- Overclaiming causality from temporal association.
- Too much identifying detail.
- A long literature review that hides the case.
- Missing diagnostic reasoning or alternative explanations.
- Claiming “first case” without a reproducible search.
Final submission checklist
- Patient publication consent is documented where required.
- Institutional/research-office route is documented.
- All images and screenshots are de-identified and authorised.
- The timeline is internally consistent.
- The learning point is explicit.
- CARE checklist completed.
- Causal language is proportionate to a single case.
- Journal-specific consent/declaration requirements checked.