The long case

Published on 14/03/2015 by admin

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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

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