Writing Case Reports in Veterinary Medicine: A Guide for Students

By Dr. Zubair Khalid, DVM, MS, PhD · 2026-08-11

Key Takeaways

• A veterinary case report documents a single patient's clinical problem and the reasoning connecting presentation to outcome, serving as an exercise in disciplined observation and structured narration for students. It is crucial to de-identify all patient and owner information that could lead to identification.
• Case reports are valuable for describing unusual presentations, rare diseases, unexpected treatment responses, or diagnostic pitfalls not covered in standard textbooks, but they cannot establish general rules or causation due to the absence of control groups and statistical power. Claims must be framed cautiously, acknowledging limitations.
• Case selection should prioritize conditions rarely reported in a species, atypical presentations delaying diagnosis, novel diagnostic techniques, or outcomes challenging existing assumptions about prognosis or treatment. A complete medical record and clinician mentorship are essential for a strong manuscript.
• The manuscript structure typically includes an introduction (briefly stating the case's relevance and background), a case description (signalment, history, examination, diagnostics, treatment, outcome in chronological order), and a discussion (interpreting the case, comparing it to literature, and stating limitations).
• Data integrity is paramount; all diagnostic imaging, laboratory results, and treatment details must be meticulously verified against original records to prevent discrepancies. For regulatory or notifiable diseases, confirm reporting obligations with relevant authorities before publication.
• The discussion section must compare the case to existing literature, explicitly stating similarities and differences, and address limitations such as incomplete diagnostic workups or the inability to establish causation. Implications for clinical practice should be framed as hypotheses for future investigation.

The case report occupies a distinct position in veterinary literature. It documents a single patient, a single clinical problem, and the reasoning that connected presentation to outcome. For the veterinary student, writing one is an exercise in disciplined observation, structured narration, and honest self-assessment. This guide walks through the entire process, from the first review of the patient record to the final revision of the discussion section. It is written for students who have completed core clinical rotations and who now face the task of converting a memorable case into a publishable manuscript.

The clinical question this article answers is straightforward: how does a student transform a case they have seen into a case report that a journal will accept? The academic question is deeper. Writing a case report forces the author to separate what was observed from what was assumed, to test their clinical reasoning against the published record, and to state clearly what the case does and does not demonstrate. These are transferable skills. Structured scientific writing improves clinical communication generally, and health professional programs increasingly treat such writing as a core competency for patient safety and continuity of care Teaching professional writing in prelicensure health professional education programs:.

At a Glance

The Purpose and Limits of the Case Report

A case report is not a small clinical trial. It has no control group, no randomization, and no statistical power. Its value lies in description. A well written case report documents an unusual presentation, a rare disease, an unexpected treatment response, or a diagnostic pitfall that the standard textbook does not cover. It can also serve as the first published description of a novel condition or a new therapeutic approach in a species.

The limits follow directly from the design. A single case can generate a hypothesis but cannot test one. It can illustrate a principle but cannot prove it. Journals and reviewers expect the author to acknowledge this distinction explicitly. The discussion section should state what the case adds to the existing literature and what questions it leaves open. This restraint is not a weakness. A case report that overclaims its significance loses credibility, while one that carefully frames its contribution becomes a useful data point for future systematic reviews.

Selecting a Case Worth Writing

Not every interesting case deserves a case report. The selection criteria should be applied before any writing begins. A case qualifies if it meets at least one of the following conditions: the condition is rarely reported in the species, the presentation was atypical enough to delay diagnosis, the diagnostic approach used a novel or underused technique, or the outcome challenges a widely held assumption about prognosis or treatment.

The student should also consider the practical constraints. Is the medical record complete enough to reconstruct the timeline? Are the diagnostic images and laboratory data retrievable? Is the attending clinician willing to serve as a coauthor and mentor? A case with excellent teaching value but incomplete records will produce a weak manuscript. The Royal College of Veterinary Surgeons Day One Competences include the ability to communicate effectively and to maintain accurate clinical records, and both skills are exercised directly in case report writing.

The Conceptual Framework: From Record to Narrative

The medical record is chronological and fragmented. It contains the owner's history, the physical examination findings, the laboratory results, the imaging reports, the surgical notes, and the daily progress entries. The case report is none of these. It is a narrative constructed from these fragments, organized around a clinical question.

The author's first task is to identify the central thread. What was the diagnostic dilemma? When did the clinician first suspect the final diagnosis? What finding confirmed it? Answering these questions before drafting prevents the common error of writing a chronological diary instead of a focused case report.

The second task is to select the data that support the narrative. Normal examination findings can be summarized in a phrase. Abnormal findings that proved irrelevant to the final diagnosis can be omitted or mentioned briefly. The goal is a complete but economical account that allows the reader to follow the clinical reasoning without wading through every recorded detail.

Structuring the Manuscript

Most veterinary journals follow a standard structure for case reports. The introduction states why the case is worth reading and provides the necessary background from the published literature. The case description presents the patient's signalment, history, physical examination findings, diagnostic test results, treatment, and outcome in a logical sequence. The discussion interprets the case in light of the existing literature, explains what makes it instructive, and acknowledges its limitations.

The introduction should be brief, usually three to five sentences. It should identify the condition or clinical problem, note that the case presents an unusual feature, and state the purpose of the report. It should not review the entire literature on the disease. The case description should be written in the past tense and should follow the chronology of the diagnostic workup. The discussion is where the author earns the reader's trust. It should compare the case to previously published reports, explain any discrepancies, and state the clinical lesson without exaggeration.

Writing for the Reader

The audience for a case report is a busy clinician who may be scanning for relevance. The title and abstract must therefore be informative and specific. A title such as "Surgical Management of a Perineal Hernia in a Dog" tells the reader nothing new. A title such as "Recurrence of Perineal Hernia after Herniorrhaphy in a Dog with Concurrent Prostatic Disease" signals a specific teaching point.

The writing itself should be clear, direct, and free of decorative language. Clinical terms should be used precisely. The passive voice is acceptable in the case description, where the focus is on the patient and the findings, but the discussion can use the active voice to state the author's interpretation. Every sentence should earn its place. If a detail does not advance the clinical narrative or support the discussion, it should be cut.

The final manuscript should be reviewed by the attending clinician and by at least one other reader who was not involved in the case. Fresh eyes will catch omissions, ambiguities, and logical gaps that the author has become blind to. This review step is part of the professional writing process that health profession educators identify as essential for producing accurate and useful clinical documents Teaching professional writing in prelicensure health professional education programs:.

Assembling the Evidence Base: Records, Imaging, and Laboratory Data

The case report stands or falls on the quality of its underlying data. Before writing a single word, you must verify that the medical record is complete, legible, and internally consistent. Pull the full record, including anesthetic charts, fluid balance sheets, nursing notes, and discharge instructions. Cross-check drug doses, administration times, and routes against the hospital's pharmacy log or the original prescription. Discrepancies between the record and the clinical narrative are the most common reason reviewers request major revisions.

Diagnostic imaging requires particular scrutiny. Re-review the original images, also the radiology report. If you are not confident in your interpretation, ask a radiologist or a senior clinician to review the studies with you and document their findings. The same principle applies to cytology, histopathology, and clinical pathology: confirm that the laboratory report corresponds to the correct patient and sample site, and that the interpretation you plan to publish matches the raw data. A case report built on a misread radiograph or a mislabelled biopsy cannot be salvaged by elegant prose.

For cases involving regulatory or notifiable disease, check whether the relevant authority requires reporting before publication. The WOAH terrestrial animal health standards list diseases that carry international reporting obligations, and national veterinary boards may impose additional requirements. Publication of a case report does not satisfy a statutory reporting duty, and in some jurisdictions it may complicate an ongoing epidemiological investigation. Confirm the legal position with your institution or the relevant authority before you submit.

Building the Chronology: From Presenting Complaint to Outcome

Construct a timeline that maps every clinical event to a date and time. Start with the presenting complaint as recorded at first contact, then add each examination, diagnostic test, treatment intervention, and reassessment. Include the duration of each sign, the temporal relationship between interventions and clinical changes, and the final outcome, whether that is discharge, euthanasia, or death. This chronology becomes the skeleton of the case description and the basis for the discussion.

For each diagnostic test, record the specific indication, the result, and the action taken in response. A normal result is as important as an abnormal one if it changed the diagnostic plan. For example, a negative heartworm antigen test in a dog with suspected pulmonary hypertension is a meaningful data point because it redirects the differential list. Similarly, record the rationale for each treatment choice, the dose and route used, and the patient's response. If a treatment was declined or delayed, document that too, and note the owner's stated reason.

The chronology must also capture the human elements that shaped the case. Record owner concerns, compliance issues, financial constraints, and communication events such as informed consent discussions. These factors often explain deviations from the ideal diagnostic or therapeutic pathway and are legitimate content for a case report, particularly when they influenced the outcome. The RCVS Day One Competences explicitly include communication and professional skills as core graduate attributes, and a case report that ignores these dimensions presents an incomplete picture of clinical practice.

Selecting and Presenting Diagnostic Images and Figures

Choose images that show the key findings clearly and add information that text cannot convey. A single well-labelled radiograph or ultrasound image is worth more than three ambiguous ones. For each image, crop to the region of interest, adjust contrast and brightness for clarity, and add arrows or labels that point to the abnormality. The legend must state the imaging modality, the patient positioning, the image plane, and the finding. If the image is from a video, such as an echocardiogram or a gait analysis, provide a representative still frame and describe the dynamic finding in the text.

Do not alter images beyond standard adjustments. Cropping, brightness, and contrast are acceptable. Removing artefacts, cloning out structures, or otherwise modifying the image content is scientific misconduct. Keep the original files and be prepared to supply them to the journal if requested.

Tables serve a different purpose from figures. Use a table to present serial laboratory values, repeated measurements, or comparisons between cases. A table that lists the patient's complete blood count, biochemistry panel, and urinalysis results at presentation, at 48 hours, and at recheck is more useful than a paragraph describing each value. The table should include the reference interval for each analyte and the laboratory that generated the results, because reference intervals vary between analyzers and institutions.

Writing the Case Description: Precision and Completeness

The case description is the longest section of the manuscript and the one reviewers read most closely. Write it in chronological order, using the past tense, and report what actually happened instead of what you intended to happen. Include the signalment, the presenting complaint in the owner's words where relevant, and the complete physical examination findings. For each body system, state what was normal and what was abnormal. A finding that is absent is as informative as one that is present, provided it was actually assessed.

Report diagnostic test results with their units and reference intervals. For imaging, describe the findings in a structured way: technical quality, then each relevant structure, then the overall interpretation. For histopathology, state the tissue sampled, the fixation and staining method, and the pathologist's report. If a test was not performed because of cost, patient instability, or owner choice, say so explicitly. Reviewers respect honest limitation more than silent omission.

The treatment section must be equally precise. State the drug, the dose, the route, the frequency, and the duration for every medication administered. For surgical cases, describe the procedure step by step, including the approach, the findings at surgery, and any intraoperative complications. For anesthetic cases, report the premedication, induction, maintenance, and recovery details, along with monitoring parameters such as heart rate, blood pressure, and oxygen saturation. The MSD Veterinary Manual, Professional Edition provides species-specific reference values for physiological parameters, which are useful when you need to state whether a monitored value was within the expected range.

The Discussion: Interpretation, Comparison, and Honest Limitation

The discussion interprets the case in light of the existing literature. Open with a brief restatement of the case and its most important finding, then compare your case with previously published reports. State explicitly what is similar and what is different. If your case is the first reported in a particular species, say that, but verify the claim with a thorough literature search first. A claim of priority that is later shown to be false is damaging to your credibility and to the journal's.

Address the limitations of your case directly. A single case cannot establish causation, and you should not imply that it can. State what the case adds to the existing knowledge and what questions remain unanswered. If your diagnostic workup was incomplete, acknowledge the gaps and explain why they occurred. If the outcome was poor, discuss whether different decisions might have changed it, but avoid speculation that the data cannot support.

The discussion is also the place to consider whether the case has implications for clinical practice beyond the individual patient. Does it suggest a modification to a diagnostic algorithm, a new way to interpret a test result, or a caution about a treatment complication? Frame these implications as hypotheses for future investigation, not as conclusions. The AVMA practice resources include guidance on evidence-based practice, and the discussion should reflect the hierarchy of evidence: a case report sits near the bottom, and its claims must be modest accordingly.

Preparing the Structured Outline

Before drafting the full manuscript, produce a structured outline that maps each section to its content. Use the following template as a starting point, and adapt it to the requirements of your target journal.

Use this outline to check that every claim in the discussion is supported by a finding in the case description, and that every finding in the case description is addressed in the discussion. A case report is a closed loop: the reader should be able to trace each interpretive statement back to the raw data, and each piece of data should have a purpose in the narrative.

Recognized Complications and Early Detection

Case reports fail in predictable ways. The most common failure is loss of documentary integrity, where the written record no longer matches the primary data. This occurs when images are cropped to improve appearance, laboratory values are transcribed selectively, or the chronology is reconstructed from memory instead of from dated entries. Detect this early by maintaining a single master document that links every statement in the manuscript to a specific record, image, or laboratory printout. Before submission, a second reader should verify that each figure legend matches the actual image and that every numerical value in the text appears identically in the source record.

A second failure mode is overreach in the discussion. The author claims a causal relationship that the evidence cannot support, such as attributing recovery to a specific treatment when concurrent interventions or spontaneous resolution are equally plausible. Detect this by asking whether the case would still be publishable if the favoured explanation were wrong. If the answer is no, the interpretation is overextended. The RCVS Day One Competences require graduates to recognize the limits of their own knowledge and to communicate uncertainty honestly, a standard that applies directly to case report authorship.

A third failure is loss of clinical context. The report describes the case as an isolated event, omitting the owner's circumstances, financial constraints, or concurrent disease that influenced diagnostic and therapeutic decisions. This omission produces a narrative that is technically accurate but clinically misleading. Detect this by reviewing the record for decisions that appear irrational without their context, then ensure those decisions are explained in the manuscript.

Common Errors and Corrective Action

Less experienced writers typically make errors of omission instead of commission. They omit negative findings that were recorded but not pursued, such as a normal thoracic auscultation in a dyspnoeic patient, because these findings seem unimportant. Negative findings often carry diagnostic weight and should be reported. They also omit the rationale for diagnostic choices, presenting a test sequence without explaining why each test was selected or why alternatives were rejected.

A second common error is temporal compression. Students frequently write "the patient deteriorated" without specifying the interval, the objective parameters that changed, or the threshold that triggered intervention. Correct this by requiring a dated and timed entry for every clinical event, with vital parameters and laboratory values stated numerically.

A third error is inappropriate extrapolation. A single case is used to support a general treatment recommendation or to challenge established practice. The corrective action is to frame the case as an observation that generates hypotheses, not as evidence that settles them. The MSD Veterinary Manual provides species-specific reference standards against which the case findings can be compared, but the comparison should identify concordance or divergence, not assert a new rule.

Limitations of the Evidence and Divergent Expert Opinion

The evidence base for case report methodology in veterinary medicine is limited. Most published guidance derives from human medicine or from general scientific writing instruction, and the transferability of that guidance to veterinary case reports is assumed instead of demonstrated. Studies of professional writing instruction in prelicensure health programs, including veterinary medicine, show that structured teaching improves writing quality, but these studies do not address the specific genre of the case report teaching professional writing in prelicensure health professional programs. Similarly, case-based instruction improves day one competency in radiographic interpretation and report writing, but the long-term effect on case report authorship has not been measured an online case-based radiology course improves veterinary students' day one competency.

Expert opinion differs on several points. Some editors require that the case report include a literature review of all previously reported cases of the condition, while others accept a focused comparison with the most relevant reports. Some journals require written owner consent for publication even when no identifying information appears, while others waive consent when images are fully anonymised. Some reviewers expect a statement of clinical significance in the abstract, while others regard such statements as promotional. These differences reflect editorial policy instead of evidence, and authors should consult the target journal's instructions before writing.

Referral, Consultation, and Regulatory Reporting

Referral is warranted when the case exceeds the diagnostic or therapeutic capacity of the primary setting. This includes conditions requiring advanced imaging, specialised surgery, or intensive monitoring that the practice cannot provide. Specialist consultation is appropriate when the case falls outside the author's core competence, even if the patient remains in the primary practice. Laboratory involvement is indicated when diagnostic confirmation requires specialised testing, such as histopathology, immunohistochemistry, or genetic analysis, and the results will materially affect the interpretation presented in the report.

Regulatory reporting obligations vary by jurisdiction and by the nature of the case. Suspected notifiable diseases, adverse drug events, and cases involving animal welfare concerns may trigger mandatory reporting to the relevant authority. The World Organization for Animal Health terrestrial animal health standards define international notification requirements for listed diseases, and national authorities publish their own reporting schedules. The American Veterinary Medical Association practice resources provide guidance on professional obligations, including record keeping and reporting, but authors must verify the specific requirements of their own jurisdiction. When a case involves a reportable condition, the report should state that the appropriate authority was notified and should reference the relevant standard without reproducing confidential communications.

Frequently Asked Questions

How do I manage the cost of diagnostic imaging and laboratory testing when writing a case report?

Diagnostic costs are a genuine constraint in case report work. Prioritize tests that directly support the clinical narrative and differential diagnosis. If advanced imaging or specialised assays exceed the client's budget, document the financial limitation explicitly in the case description and discuss how it constrained diagnostic certainty. Standard hematology, biochemistry, and survey radiography often suffice for a valuable report when interpreted rigorously. Reference ranges and interpretive guidance for common species are available in peer-reviewed veterinary references such as the MSD Veterinary Manual. State clearly in the limitations section which diagnostic steps were omitted for financial reasons and how that affected the conclusions.

What should I do when the ideal diagnostic equipment is unavailable at my institution?

Describe what was available and what was not, then explain the diagnostic workaround. A case report retains value when it demonstrates sound reasoning under real-world constraints. For example, if computed tomography is unavailable, document how orthogonal radiography and ultrasonography narrowed the differential list. If histopathology cannot be performed, say so and identify the residual uncertainty. The Royal College of Veterinary Surgeons Day One Competences emphasize working within available resources while maintaining professional standards. Reviewers accept resource limitations when the author acknowledges them honestly and explains their impact on the diagnostic conclusion.

How does the case report format change for food animals or exotic species compared with small animals?

The structure remains constant, but the emphasis shifts. For food animals, include production context, herd-level implications, withdrawal period considerations, and economic impact. For exotic species, note that reference intervals are often extrapolated from related domestic species and state this explicitly. Regulatory considerations differ by jurisdiction and species, so consult international animal health standards from WOAH where reportable disease is a possibility. The discussion should address species-specific pathophysiology and therapeutic constraints. Do not assume that a treatment validated in one species transfers to another without evidence.

What level of detail should I include about record keeping and data provenance?

The case report is only as reliable as the source record. State the date of each examination, who performed it, and which equipment generated the data. Note any discrepancies between the medical record and the owner's account. If images were reviewed retrospectively, say so. If laboratory results came from an external laboratory, name the laboratory type and the assay platform where relevant. The scoping review on teaching professional writing in health professional programs identifies accurate documentation as a core professional skill. Clear provenance allows reviewers to assess data quality and allows readers to judge whether the conclusions are proportionate to the evidence.

How should I explain the case report process to the owner and obtain consent?

Explain that a case report is an educational publication that describes the animal's condition and treatment without necessarily revealing the owner's identity. Obtain written consent before starting the manuscript, and confirm whether the owner permits photographs or videos of the animal to be published. Explain that the report may not benefit the animal directly but may help other animals with similar conditions. If the case involves a potential welfare concern or a notifiable disease, explain any mandatory reporting obligations before discussing publication. The AVMA practice resources provide general guidance on professional communication and client relationships that applies to this conversation.

What do I do if my supervisor and I disagree about the interpretation of the case?

Resolve the disagreement before submission. Re-examine the primary data together, particularly the images and laboratory results, and identify the specific observation that drives each interpretation. If the disagreement concerns prognosis or treatment response, review the follow-up records. Where genuine uncertainty remains, present both interpretations in the discussion and explain why the evidence does not permit a definitive choice. This approach mirrors the honest limitation section described earlier. If the disagreement concerns professional conduct or a potential error in care, follow your institution's incident reporting pathway first. A case report is not the appropriate venue to litigate a dispute about clinical judgment.

Related Clinical & Scientific Guides

• Veterinary Case Presentation: Structure and Delivery
• Veterinary Communication in the Workplace: Team Dynamics
• Monitoring Plans for Hospitalized Veterinary Patients

References and Further Reading

• Development of a neuroscience-oriented "methods" course for graduate students of pharmacology and toxicology.. 2006.
• Experimental methods in neuroscience: an undergraduate neuroscience laboratory course for teaching ethical issues, laboratory techniques, experimental design, and analysis.. 2003.
• Teaching professional writing in prelicensure health professional education programs: a scoping review.. 2025.
• An online case-based radiology course improves veterinary students' day one competency in small animal radiographic interpretation.. 2025.
• Reflections on an International Research Immersion Field Study as a High Impact Practice to Produce Publishable Papers by Underrepresented Undergraduates.. 2019.
• Equine virtual farm: A novel interdisciplinary simulation for learning veterinary physiology within clinical context. 2011.
• RCVS Day One Competences. RCVS.
• MSD Veterinary Manual, Professional Edition. MSD Veterinary Manual.
• American Veterinary Medical Association Practice Resources. American Veterinary Medical Association.

Related Articles

• Case Presentation Format for Veterinary Students: A Practical Guide
• Veterinary Case Presentation: Format and Examples for Students
• Veterinary Case Presentation: Structure and Delivery
• Developing Clinical Reasoning Skills in Veterinary Students
• Suture Practice Kits for Veterinary Students: What to Look For

This article is educational professional reference material for veterinary audiences. It is not a substitute for veterinary diagnosis, individual clinical judgment, current product labeling, or applicable regulatory requirements.