The long case

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Chapter 5 The long case

We are what we repeatedly do. Excellence, then,

is not an act, but a habit.

Aristotle

Traditionally, the long case section of the exam has a relatively good pass rate and many candidates view it as the easiest component of the examination to prepare for. Despite this, obtaining a good result requires specific preparation and planning.

Purpose

The long case is the examiners’ opportunity to see how candidates ‘put it all together’ and therefore is your opportunity to showcase what you do on a daily basis. Four principles mentioned earlier in the book are tested in detail:

1. How you perform during a usual day at work. Taking a full history and examination, and deciding on initial investigations and management are absolutely core business for the specialty. Any clinical area may be presented, including paediatric and obstetric cases.

2. How you identify and manage what iscommonandcommonly deadly. The majority of long cases are sourced by local venue organisers who ‘spot’ the cases in their own ED in the lead-up to the exam. This may include ‘hot’ cases just admitted to hospital. Cases that appeal to examiners are those with a story to tell, clinical signs to find and a total ‘package’ relevant to the practice of emergency medicine. Only a small percentage of patients come from outpatient areas without having been through ED. Questions that will be asked relate only to actual or possible ED presentations and focus on common and potentially lethal issues.

3. How you attend to the 3Cs. Concentrate on condition (diagnosis), cause (cause of the principal condition and/or precipitating factors for acute presentations) and complications (actual and potential).

4. How you demonstrate practice at the level expected from a FACEM. Judging how you engage with the examiners in a scenario where you are expected to perform as a competent junior colleague is a great way to find out whether you fit the bill.

Format

There is only one long case. You may take in your exami nation kit but not any written material. Notes are to be written on paper provided. You have 35 min utes with the patient to spend however you choose, followed by five minutes sitting outside the exam room to organise/consolidate/prepare your thoughts and written notes, followed by 20 minutes with two examiners for your presentation and questioning. During your time with the examiners, one examiner will direct the questions while the other mostly observes and takes notes. The second examiner may occasionally ask questions to clarify issues, but typically remains silent. This pattern will continue for all the clinical components of the examination and is designed to ensure fairness and consistency. While one examiner is leading the discussion, the other is checking that you have addressed the relevant material. Both examiners agree on the final mark using these notes. Should you be unsuccessful in the examination overall, these notes will be used to provide you with feedback.

The examiners see the patient immediately before the exam without having access to the clinical notes. They decide what history can be elicited and what clinical signs are present (including relevant negatives) and determine how complex the case is. Both examiners see the patient to confirm the findings. Aft er examining the patient, the examiners decide the direction of questioning of the candidates. The clinical notes are used, as they are in normal practice, to confirm the history as well as provide results of investigations. You will be expected to discuss any results as they relate to the case.

The presentation

The examiners usually allow candidates approximately 12–13 minutes for the presentation, during which time they will interrupt only to clarify an issue, not to ask questions regarding management. You are expected to provide all the details of a comprehensive patient evaluation — including the presenting complaint, past history, social history, medications, allergies, systems review and results of physical examination — and it is recommended that you end with a brief summary.

Start your presentation by providing a brief but informative introductory synopsis. You can modify the detailed summary of diagnostic or management problems from the notes you have already made and present it briefly as the synopsis, so this section does not need to be prepared separately. Your synopsis may focus on outlining diagnostic uncertainty and/or management problems, depending on which issues are more pressing from your perspective as a FACEM or from the patient’s or family’s viewpoint. The ‘tree trunk’ synopsis is the solid structure from which the rest of your long case presentation or ‘branches’ hang from and depend on.

The introductory synopsis naturally leads into a systematic presentation of the details of the case. For each section of the presentation, it is important to first mention the relevant positives or negatives that provide evidence for or support your synopsis and to use succinct language. For example, a systems review of a patient with a recent stroke could encapsulate a brief statement such as:

On systems review, the patient has no clinical or historical features suggesting aspiration pneumonitis or pressure areas, but does have bowel disturbances associated with persistent immobility. There were no other symptoms relevant to the cardiovascular, renal, haematological…

This impresses on the examiners that you have approached the long case in a focused, relevant manner, rather than casting a wide net by asking questions from a comprehensive template attempting to cover everything.

Finalise your presentation with an end-of-case summary that elaborates on, rather than is identical to, your introductory synopsis. Whereas the opening synopsis introduces the diagnostic and management issues, the summary reinforces these and leads on to further investigation and treatment in priority order.

At the end of your presentation, the examiners may clarify some points or, unless you beat them to it, they will typically begin with the actual or potential ED presentations that could be expected with this patient. You may be shown results of investigations or other material from the patient’s clinical notes as part of the discussion. All questions will relate specifically to this patient and thus will vary from you being asked about a provisional diagnosis, a diff erential diagnosis and/or an investigation plan, right through to detailed management.

Assessment criteria

The examiners will have decided on the key criteria prior to the commencement of the examination and the complexity and difficulty of the case will be taken in to consideration. You will by assessed on the completeness, organisation, quality and timeliness of your history, examination findings, diagnostic assessment, plan of investigation and management of issues, as well as how you respond to questions and your overall ability to communicate at the level of a specialist.

Preparation

General preparation for this section of the exam is relatively easy as it covers very much what you do every day. Therefore, the best preparation is to remem ber the core principles (see Chapter 1) and use them constantly: all are relevant for the long case.

Most cases will have chronic, often multi-system diseases with a number of historical and examination findings. Time spent as a medical registrar and in specialty clinics will serve you well.

The principal difference between the long case and your everyday work is the long case’s time constraint. Therefore, you need to practise and become comfortable working within this time frame. The more practice cases you do, the easier it becomes to develop a ‘feel’ for how best to spend the 35 minutes for both the history and examination, how to structure your presentation and anticipate likely lead questions during the five-minute interlude, and how to deliver your presentation in about 12 minutes. We recommend that you practise a minimum of 10 cases under examination conditions with a suitably experienced ‘examiner’.

Table 5.1 outlines important cases to review, although this is by no means an exhaustive list of what you can expect to encounter in the exam. Look out for patients with these conditions at work during your exam preparations. It is always beneficial to have seen actual patients who can literally be ‘walking textbooks’. Recalling your management of actual cases is easier than trying to remember lists from texts.

TABLE 5.1 Long cases you should be familiar with

Cardiomyopathy

Chronic liver disease (e.g. alcoholic, Wilson’s disease, haemochromatosis)

Chronic neurological conditions

• motor neurone disease

• multiple sclerosis

• muscular dystrophy

Chronic renal disease — especially on peritoneal dialysis or haemodialysis

Chronic respiratory disease (e.g. COPD, fibrosing lung disease)

Connective tissue disease

Diabetes mellitus with complications

Haematological conditions

• chronic anaemia (e.g. sickle cell disease, thalassaemia)

• myelodysplasia

• myeloproliferative disorder (e.g. polycythaemia vera)

Immunodeficiency with complications

Inflammatory bowel disease

Ischaemic heart disease

Malignancy — especially with complications (e.g. metastases, organomegaly)

Neurofibromatosis

Rheumatoid arthritis

Stroke with residual weakness or functional impairment (e.g. neglect)

Transplant recipients — heart, lung, kidney

The patient with multiple co-morbid problems

Examination Medicine (by NJ Talley and S O’Connor; Churchill Livingstone, Sydney) is an excellent resource to assist preparation for medical cases, although it must be appreciated that there is by necessity a different focus for the FACEM exam, with the emphasis on departmental management rather than long-term care.

Considering how the 3Cs apply to each potential long case problem will enable you to pre-empt and prepare for the obvious relevant questions you could be asked in the exam. Some examples of this approach are provided in Table 5.2.

TABLE 5.2 Examples of the 3Cs as they apply to some common long cases

On the day

Time with the patient (35 minutes)

You may be provided with the patient’s medication chart (if an in-patient) or the patient may have a list. If not, compile a list as best you can — as you would during a clinical shift in ED. Some observations may be provided where pertinent, but none should be expected or demanded. If you want a blood pressure and it is not provided, measure it. If fundal exami nation is relevant to the case (e.g. diabetic, stroke, visual field defect), you will be provided with an ophthalmoscope. However, potentially embarrassing examinations such as PR or PV examinations are not to be undertaken. You will have time with the examiners to say what other aspects would make part of your normal examination. Where relevant, these findings will be provided by the examiners.

For outpatients, start with their previous presentations, remembering one of these may be the starting point of discussions with the examiners.

History taking and examination

Introduce yourself to the patient and thank them for taking part. Apologise that you are rushed for time and so may be more abrupt than you usually would.

Aft er you have established rapport, take a history using a focused approach, with headings that you have practised and are familiar with. This process is not mechanical; it requires interacting with, and hearing, the patient. Informative questioning requires you to synthesise information as it becomes available, and to adjust the choice and emphases of subsequent questions accordingly. Although you are dutifully fol low ing predefined headings, you need to ask questions that relate to the important issues for this patient, as they will be the likely focus the examiners will take. A good patient historian will provide you with a logical, sequential and relevant narrative, but some patients will require repeated but courteous redirection.

You need to have alternative strategies if the patient is a teenager or has a cognitive or communication disorder. Remember that teenage patients in long cases often have chronic diseases such as cystic fibrosis and frequently have illness behaviour that has resulted from chronic hospitalisations. Your communication strategy needs to be sensitive to these limitations and adjusted accordingly. The examiners will be aware of these difficulties and will have taken them into account. Where communication is difficult, it is likely there will be a greater focus on clinical findings and/or a collateral history will be required.

Continue the history while examining the patient. Where necessary, the history can be supplemented as you discover more physical signs. Commence examination as soon as is practicable; ensure that the patient is adequately undressed but not immodestly or uncomfortably so. Remember, other candidates may have already seen this patient, which is advantageous if they are better versed at what they are expected to tell or show you, but a disadvantage if they are tired, bored and irritable. Be attuned to the patient’s mood state; do not hurry the examination if this is likely to be perceived to be uncaring.

Even if there is no apparent indication, the physical examination should address every system, at least briefly. An unexpected cardiac murmur or large scar on the back the patient has forgotten to mention will be more than embarrassing when you are asked about it later.

It is worthwhile spending a minute at the start of your allocated time setting out your paper in the way you have practised, as this will help prevent omissions. An example of some section headings to consider is provided in Table 5.3. Modification is needed for diff erent types of patients (e.g. a birth, developmental and immunisation history will be most relevant for children).

TABLE 5.3 Possible subheadings for the long case presentation

Presenting complaint

History of presenting complaint

• alcohol and illicit drug use

Medications

• prescribed

• natural therapies

• over-the-counter agents

Allergies

Immunisations

Diagnostic list

Management strategies

Summary of key points for the presentation

* Developing a mnemonic for the various systems is a good way to ensure all systems are covered.

Organise your notes so that each section is on a different piece of paper (or is clearly delineated if multiple pieces of paper will be difficult for you to manage). This will enable you to add, change and rearrange the sections depending on how you wish to present the case later. It will also act as a handy reference should you be asked a question regarding something you know you asked but cannot recall the detail.

The long case, more than any other component of the fellowship examination, is an opportunity to demonstrate your ability to address the 3Cs. The diagnosis (condition) will be a focal point of your initial discussion with the examiners. Initial management, investigations and subsequent in-hospital course are all related to actual or potential complications. The discussion on management of the patient will have to address precipitating factors (causes) before discharge or the patient will re-present. Specifically considering the 3Cs during your time with the patient will help guide you, and may prompt you to gain more history and/or examine for a particular feature that may otherwise have escaped your attention.

Aim to finish your history and examination with time to spare before your 35 minutes are up. Make sure you ask the patient whether there was anything the examiners seemed particularly interested in or any aspect of the history or examination they elicited that you have not. Having spare time will enable you to explore more detail if needed, confirm any findings you were unsure about and commence the process of collating your thoughts. If you start this while you are still with the patient, you have the opportunity to complete any ‘gaps’ that may suddenly come to mind.

The five-minute break

The five minutes will pass very quickly, so be prepared for what you need to do during this time. By now you should have identified the key features of the history and examination, so use the time to consider your introductory synopsis and your closing summary and how you will proceed after the presentation. If you are happy with the clinical scenario, write down the key points so that you can present them in your introductory synopsis. Similarly, for your closing summary, consider the issues and make a bullet point list to refer to, putting the issues in priority order and noting whether they are active or inactive.

Arrange your sheets of paper in the order you wish to present them or clearly number the sections if you have not used one piece of paper for each item. Check again to ensure completeness and whether there are potential areas of discussion that you have not considered.

At the end of the presentation, the examiners will ask you some questions. Initial questions will relate to ED presentations (actual or potential for this patient). Use this time to consider what those questions are likely to be, organise your thoughts and prepare your responses. You should also decide whether you wish to lead or be led in this ‘dance’ with the examiners.

The presentation and discussion

When you enter the exam room, assume that you are about to have a discussion with colleagues. Enter as a consultant would. Be confident but not overly so, sit comfortably and use appropriate body language. If you are prone to nervous hand movements, develop a way of controlling this — such as always keeping your hands on either side of your notes. Remember to address the active examiner and the co-examiner by maintaining eye contact with both.

If you are comfortable with the overall scenario, let the examiners know this from the outset. For example:

I saw Mr Jones, a 45-year-old man, currently in hospital having fallen two weeks ago while intoxicated and suffering a neck of femur fracture. He is an alcoholic and describes features of withdrawal last week, and his social circumstances of living alone in a hotel need to be addressed before safe discharge can be effected. His history in more detail…

If the scenario is not straightforward, an initial brief synopsis is still possible. There are plenty of patients on wards and at home who do not have firm diagnoses. However, they all have conditions that can be addressed as a management plan or working diagnosis. Presenting this reassures the examiners that you are able to rationally synthesise and appropriately manage uncertainty.

Present as a FACEM, not as a medical student, and give only positive findings and relevant negatives. Long lists of irrelevant negatives put the examiners to sleep, serve to confirm that you are not able to present as a FACEM and, most importantly, consume time you could be using to demonstrate your diagnostic and management abilities.

Do not apologise or complain if the history and/or examination were difficult. The examiners saw the patient before you and will take this into account when deciding on your mark. A more productive approach is to present the ‘difficulty’ with constructive suggestions to manage it. Compare these presentations of the same issue:

[Apologetic] I’m sorry, I couldn’t get a proper history from Mr Jones because he kept changing his story and couldn’t remember details. I don’t trust it and I’m not sure what is real or not. He said he lived alone but then said he lived with friends…

[Productive] Mr Jones’ history was incomplete and inconsistent. Given his features of alcoholic liver disease this is most likely confabulation. I would confirm all of the history with reliable sources. With this in mind, the history obtained was…

You have approximately 12–13 minutes for your presentation and will be interrupted only to clarify a point or if you are running out of time for the examiners to ask questions.

When the questions do commence, expect the first one to be ‘Describe your approach to the patient if they presented to your ED as they did on [this or a particular past] presentation’. In the less common scenario where the patient has had no acute ED presentations, this first question will most likely be in relation to a common acute presentation with this clinical condition. Because you know what the question is likely to be, you may choose to lead into it — as a ‘real’ FACEM would.

If Mr Jones presented to my ED with a painful hip following a fall, I would rapidly assess him for other injuries or threats to life and manage them accordingly. If there were none, my first priority would be analgesia followed by confirmation of diagnosis and evaluation for co-morbid conditions. Specifically, my approach would be…

If the examiners wish to discuss a different presentation or potential presentation, they will redirect you. If so, you have lost nothing by demonstrating initiative.

The remainder of the discussion will be relevant to the case. Therefore, a similar strategy can be adopted and after addressing the first question, you may choose to continue with ‘interesting’ aspects, as a FACEM would discuss them. If you lead, the examiners may choose to let you continue a pertinent discussion rather than having to lead you. Think of what is common and what is commonly deadly for this patient. Any of these should be considered likely discussion points, as well as uncommon features that imply a complication or an alternative diagnosis.

A suggested ‘style’ is to raise an issue, remark why it is relevant, discuss possible explanations and suggest how you would address it. This can then lead to other relevant issues, which can also be presented in the same manner. For example:

It is unusual for a man of this age to sustain a neck of femur fracture. Presumably this is related to malnutrition, but I would examine the initial films carefully to ensure this was not a pathological fracture. Mr Jones’ in-patient course was complicated by withdrawal symptoms that were managed in the usual way.

Of interest, however, is that he has only a sketchy recall of the last week other than receiving blood transfusions and what sounds like an upper GI endoscopy. This is not common for a simple #NOF. My suspicion is that he may have had an upper GI bleed related to his alcohol abuse. For him, the most likely cause would be peptic ulcer. There were no stigmata of portal hypertension, so a variceal bleed would be less likely although should still be considered. With a GI bleed, encephalopathy could result, which may have impaired his memory even more so for that period and potentially could even be why his history is inconsistent now.

He has no asterixis now so, if encephalopathy was present, it is no longer an active consideration. I would like to clarify that he has received thiamine…

The examiners may choose to stop you if they intend to discuss any of the features you raise. Alternatively, they may let you keep going, so long as you are describing relevant features, discussing the pros and cons of possible diagnoses and management options, and keeping to the case at hand. If they do not stop you and you have presented all the ‘interesting’ aspects you have on your list, start going into more detail for one of them.

Upper GI bleeds present a particularly interesting management issue in alcoholics. From the emergency medicine perspective, the principal conditions to consider are…

Should you be redirected by the examiners, listen carefully to the question and answer it. Do not be concerned: redirection means either the examiners have decided the current line of questioning has demonstrated your abilities, their focus is in a different direction or they want to explore more ‘breadth’ instead of just ‘depth’. Maintain the same confident approach you brought into the room for a discussion with fellow colleagues until the bell goes

Key points

• Practise your long case technique with every patient you see at work.

• Take opportunities to practise with an ‘examiner’ under exam conditions.

• Practise a format for presenting your case which pre-empts examiners’ questions.

• Consider potential emergency presentations relevant to your case while preparing your presentation.

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The long case

Purpose

Format

The presentation

Assessment criteria

Preparation

On the day

Time with the patient (35 minutes)

History taking and examination

The five-minute break

The presentation and discussion

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