The Long Case

Published on 21/03/2015 by admin

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Last modified 22/04/2025

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Chapter 2 The Long Case

Most candidates have a small leather briefcase (or equivalent carrying bag) for their equipment. Be absolutely familiar with the equipment you have in your bag. Nothing looks worse than a candidate fumbling through his or her bag or, worse still, his or her pockets at the vital moment.

On the day of the examination, in Australia, there are two long cases, one in the morning cycle and one in the afternoon cycle, and the candidate is examined by two sets of examiners. For each long case, the candidate is given 60 minutes with the patient and parent(s); then 10 minutes organising the case, and finally 25 minutes with the examiners. The candidate must take a full history, perform a relevant physical examination and synthesise a management plan that is sensible and appropriate for the particular child. The examiners will not interrupt the presentation of the history and examination findings unless there is, exceptionally, a specific key point that requires clarification. The entire presentation should take between 10 and 12 minutes, generally 7–8 minutes presenting the history, 2–3 minutes presenting the physical examination then one minute for a summary, before launching into management. Practice is the key to success.

Practising long cases is extremely beneficial for improving your clinical skills, irrespective of the examination looming in the distance. Practice cases should be performed under examination conditions whenever possible. Most consultant paediatricians are quite willing to spare 20–30 minutes to listen to candidates presenting cases. Advanced trainees who have recently passed are also usually prepared to act as examiners for candidates.

Obtaining the history

The aim of the long case is chiefly to assess how you would manage the child, his problems and his family. The examiners want to know whether or not you can competently care for a patient in practice. The history in the majority of cases will provide you with the diagnoses.

You must allocate your time with care. Generally, 20 minutes should be spent on the history, 10–15 minutes on the physical examination and the remainder of the time on recording, reviewing and organising the information for presentation. This time spent on organisation is the most important.

Making notes is vital. Two commonly used methods are:

1. Using a small spiral-bound pad.

2. Using a small card system: numbering the cards, and using headings such as ‘examination findings’.

Remember to keep to the essentials and to include the following:

1. Identification of the child’s details—age, date of birth, home address.

2. Identification of the clinical problem(s).

3. Specific inquiry of system involvement.

4. Relevant past medical history: include birth history, immunisation history.

5. Present treatment.

6. Growth and development.

7. Social history: always ask about parental relationships, number of children, family income, financial support, other siblings’ reactions to the patient’s illness, schooling.

Always introduce yourself to the child and parent(s). Always be courteous, diplomatic and tactful, use basic English and never order them about. Explain to the parent(s) that this is a very important examination.

The following questions have been found useful by many candidates:

1. What exactly is wrong with your child?

2. Is your child an inpatient at the moment?

3. What are the names of the doctors taking care of your child?

4. What tests have been done on your child? Have any new tests been done lately? How often do you come for review? How many times has your child been admitted?

5. What treatment is your child on? Have there been any recent changes in your child’s treatment?

6. What is worrying you the most?

7. What is worrying the doctors the most?

8. What is worrying the child the most?

9. What complications of treatment are there?

10. What of the future? For the family? For the patient?

11. Is there anything else that someone else has done or asked that I haven’t done or asked?

Remember, do not accept the patient’s history without questioning.

Make a list of all the important problems and then organise this list so that the most important or current issue is presented first, followed by the other problems in decreasing order of importance.

Physical examination

Remember to keep to essentials and look at the front, back and both sides. Ask the parent(s) what the examiners looked for when they examined the child. A detailed examination should be done of those regions related to the child’s main complaint. Following the specific examination, other systems need to be assessed. Remember to assess growth parameters, blood pressure, oral cavity and the skin.

Preparation to meet the examiners

After completing the history and examination, always ask yourself: ‘Have I left anything out?’ and ‘Can this be anything else?’

Study your notes thoughtfully, underline or highlight positive findings and ‘box’ all relevant negative findings. This is the information you will present to the examiners.

Ask yourself whether the case is mainly a management or a diagnostic problem. If it is a diagnostic problem, remember that ‘common things occur commonly’. If more than half of your findings support your first diagnosis, then it is most likely the correct one. For your alternative diagnoses, take the main positive findings and have three possible diagnoses for each. Make a summary of the possible diagnoses that occur three or more times.

Create an introduction that is clear, concise, arouses interest and summarises the main problems. It should last no longer than 30 seconds. Remember: first impressions are important, so spend time mentally rehearsing the delivery of your introduction. (See below for a long-case proforma.)

Mentally rehearse your order of presentation; present the most important issues first. Keep some issues in reserve so that when the examiners ask you about them, you will be able to provide immediate answers, rather than laying all your cards on the table immediately. Your conclusion should re-emphasise the main problems in order of decreasing importance. The entire presentation of the history should last no longer than 7–8 minutes.

Try to anticipate possible lines of questioning, and think up reasonable answers in advance. Common questions asked by examiners include:

1. ‘Tell me about your patient’. You should be able to give a clear, concise presentation lasting less than 10–12 minutes.

2. ‘What is your conclusion about this case?’ You should respond by giving a most likely diagnosis and differential diagnoses. Avoid giving an over-comprehensive list of differential diagnoses.

3. ‘How would you manage this patient?’ You should prepare an outline of management and be able to support it. You are probably going to be asked about relevant investigations. You should have reasons for doing the test and be able to discuss the test in detail. Write down any test results given and comment on their significance.

Assume that the examiners are there to help you. If an examiner continues to ask a question even though you do not immediately know the answer, he or she may be attempting to establish a very basic fact. Try to step back mentally for a moment; the answer is often forthcoming. Do not waffle. If you do not know the answer to a question, do not be afraid to admit it, but do so confidently. This allows the examiner to change the line of questioning and, hopefully, ask you a question that you can answer. Always be prepared to justify any statement you make in the ‘viva’.

A long-case proforma

Although proformas cannot be taken into the examination, it is very useful to have a standard commencement to a long-case presentation that is second nature to you. It is suggested that you may use proformas in practice cases; the author used the proforma below successfully with each and every long case.

Opening statement

‘I have just seen [name of child], a [age in months or years] old boy/girl with a [duration of time] history of [presenting complaint], who is currently in hospital for [reason for being in hospital that day]. [Name of child]’s problems include [list of each diagnosis in order of importance, or in the case of a multisystem disease, each aspect as it arose in chronological order]. I shall discuss the history of each problem in this order’.

Details and history

Next, the presenting complaint is set out in detail.

Then, for each problem listed in the opening statement, make four columns, with the headings Dates (or age of child), Past history, Current status, Recent changes. The history is listed in chronological order under each heading. For example, if the problem was nephrotic syndrome it could be listed as in Table 2.1.

Table 2.1

image

Remaining history

When you have completed the problem listing sheets, remember to ask the parent supplying the history, ‘What did the examiners ask you?’ Then the rest of the history can be obtained. The prompts given in Table 2.2 may help.

Table 2.2

Birth history
Date of birth__________​/Birth weight__________​/Hospital__________Pregnancy: Drugs__________​/Bleeding__________​/Illnesses__________Hyper​/hypotension__________​/Hospitalisations__________Ultrasounds__________​/Other tests__________Polyhydramnios:__________​/Fetal movements:__________Planned?__________​/Gestation__________​/Delivery method__________Apgar scores__________at 1 minute __________at 5 minutes
Perinatal history
Respiratory distress__________​/Oxygen requirement__________Feeding: Breast__________​/Bottle__________​/Tube__________Jaundice__________​/Weight gain__________​/Other problems__________Discharge date​/age__________​/Discharge weight__________
Feeding history
Currently__________​/Breast​/bottle: until__________​/Solids: since__________Past feeding history__________
Milestones
Good baby?__________​/Hearing__________​/Smiled__________Compared to sibs__________​/Sat__________​/Sleeping behaviour__________Crawled__________​/Feeding self__________​/Walking__________Toilet trained__________​/Talking: single words__________Sentences__________School compared to sibs__________​/Vision__________Current developmental abilities​/problems:Vision__________​/Hearing__________​/Gross motor__________Fine motor__________​/Language__________​/Personal social__________
Family history
Mother: Name__________Age__________ Job__________ Health__________Father: Name__________Age__________ Job__________ Health__________Note any consanguinity__________​/Planning any more children?__________Relevant family history__________​/Other diseases in family__________Previous marriages__________Past pregnancies: Terminations__________​/Miscarriages__________Children who have died__________Family interactions__________​/Family supports__________Family’s understanding of disease: Mother​/Father​/Sibs__________
Social history (can be the most important)
Financial status__________​/Private health insurance__________Home__________​/Car__________​/Allowances__________Family supports__________​/Other supports__________Societies__________​/Magazines__________How long in Australia?__________
School history
School attended__________​/Grade__________​/Performance__________Subjects__________​/Sports__________​/Friends__________Ambitions__________​/How much school has been missed?__________Repeated any grades?__________
Parents
Change in social life__________​/Parents’ friends__________Last holiday?__________​/Respite care? __________
Home
Any structural changes to cope with the illness?__________
Transport to school/doctor
Need for special transport__________/Financial burden of transport__________
Other past history
Infections__________/Fractures__________Operations__________/Hospitalisations__________
Immunisation
Up to date?__________/Given on time?__________Any missed?__________/Adverse reactions?__________
Allergies
Presenting symptoms: Rash__________/Angio-oedema__________/Anaphylaxis__________ Requirement for adrenaline?__________/Medicalert bracelet__________
Most serious problem
Mother’s opinion__________/Father’s opinion__________Patient’s opinion__________/Doctor’s opinion__________
Parents’ understanding of disease
_________
Compliance
_________
Alternative medicine
__________
Systems review
Cardiovascular/Respiratory/Ear, nose, throat/Eyes/Gastrointestinal tract/Central nervous system/Skin/Joints/Endocrine/Renal/Haematological
Home management
Medications Side effects Levels
Note: List the above under headings: many long-case patients are on multiple drugs.
Other management
Physiotherapy__________/Occupational therapy__________Speech therapy __________/Other therapy__________Daily routine__________Clinics attended__________Specialists seen regularly (what do they ask/do/examine?)__________Local doctor__________Paediatrician __________

Examination

For the examination, it is always best to start with a general description of the patient, as if you were describing a photograph over the telephone. Again using the example of nephrotic syndrome, an opening line could be: ‘On examination [name] was a 4-year-old Cushingoid boy, with moon face, a swollen abdomen and a swollen scrotum, with an intravenous line in the left forearm’.

Next, describe the parameters (head circumference, weight, height) and show the examiners the centile chart (which you have of course plotted at high speed). The vital signs (pulse, respiratory rate, blood pressure, temperature and, if relevant to the presentation, urinalysis) may then be given, and then the findings in the organ system most relevant to the child’s current clinical problems. Again, using the nephrotic syndrome example, this would be similar to the following: ‘Examination of the renal system was as follows: periorbital oedema, ascites, tense scrotum, no effusions, Cushingoid features (buffalo hump, loss of supraclavicular fossa), but no striae, cataracts, not short, no acne, no bone pain, no bruising’.

During the examination of the child, ask the parent again, ‘What did the examiners look at yesterday?’ After the relevant system, examine the other systems too: cardiovascular, chest, abdomen, ear, nose and throat, central nervous system, and where appropriate, developmental assessment.

After the examination findings, present a summary, reiterating the important points. Following this you have the opportunity to discuss the management plan that you, the candidate, would initiate. There are several useful phrases that may help you start this discussion, such as:

• ‘As regards management, my main concerns are …’, or

• ‘With respect to [problem], as the paediatrician looking after [patient], I would …’, or

• ‘In the line of investigations, I would …’

Remember to have a list of issues ready to discuss confidently.

The criteria used to assess performance in the long case have five headings (assessment domains): history, examination, synthesis and priorities, impact of illness on patient and family, and management plan. One of the examiners will have already taken the history and examined the patient ‘cold’, before the first candidate, and presented to their fellow examiners, without seeing any notes or prepared history, such that the circumstances are as close as possible to those the candidate will experience; the examiners know what sort of historian the parent may be, and will have determined the priority list of clinical problems for themselves. The examiners then spend some 20 minutes reviewing the notes, and a prepared long-case summary sheet, which outlines the diagnoses, problems and the examiners’ key issues. Also, all examiners will have undergone a calibration session in the weeks before the examination, to ensure consistency and fairness.

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