The Long Case

Published on 21/03/2015 by admin

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Last modified 21/03/2015

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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.

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