Examination Medicine: A Guide to Physician Training, 7th Edition

CHAPTER 4. The long case

In what manner are the examiners elected? Are they elected by the profession or any part of the profession whose interests are equal to those of the whole and are they responsible to the profession at large for their conduct?

Neither the one nor the other.

Lancet 1824; i:20

When the examiners discuss a long case with a candidate they are expecting to find out how the candidate would manage the patient and his or her problems. They want to know whether the candidate has a practical grasp of what is required in consultant practice. Candidates are expected to have a mature and sensible approach to the patient and his or her problems. It may help to picture yourself as the physician taking over the care of a new patient. Practising long cases trains candidates to be better clinicians.

Careful allocation of time with the patient in the long case is vital. The exact proportions will depend on the case itself, but, as a rough guide, spend 25 minutes on the history-taking, 15 minutes on the examination and the rest of the time preparing discussion and reviewing vital facts with the patient. Remember though, that you can continue to ask the patient questions as these occur to you while you are examining. Nothing is more important than ensuring you leave enough time to put your thoughts in order.

Candidates favour many different systems for recording long-case details (as an aid to memory or aide memoire). There are two we recommend: one is to use a pad that can be held comfortably in the hand and the pages turned unobtrusively. Most candidates now use a large card folder, one side of which is used for the history and the other for the examination findings; a second card (if necessary) is used for relevant investigations, management and short lists of facts you may wish to mention. Obviously, numbering each side is important, so as not to mix up the order of presentation. These cards are usually provided to candidates who want them at the examination site. Mixing up the cards can be a disaster. One candidate was sitting, preparing to enter the examination room, when the side door opened and a puff of wind blew the cards out of her hands. She was then ushered straight into the examination room with the cards in random order. She began the long case badly and failed.

Candidates who do not want to rewrite the whole long-case presentation before facing the examiners (time is often a problem) may find it helpful to number the paragraphs with a red pen in the order in which they wish to present the story.

Many examination centres provide manila folders. These are large enough for candidates to be able to write out one whole long case on one folder. They do, however, seem to lead to a lot of turning backwards and forwards and folding and unfolding as candidates search to find where something was written. Practise with whatever method you choose so that it works smoothly.

The history-taking and physical examination

Once you have said, ‘How do you do?’ to the patient at the beginning of the long case, we suggest initially following the steps outlined below. Remember though that there is no single right way to conduct any part of the exam. This book is meant only to provide a framework upon which candidates can work out what suits them best. These steps may help you rapidly ascertain the patient’s major problems so that you can direct further questioning more easily.

1. Explain to the patient that this is a very important examination. Gain the patient’s interest and support. This is a test of bedside manner.

2. Ask the patient what is wrong. If he or she asks, ‘Am I allowed to tell you?’, look confident and firm and say, ‘Yes, of course’. Candidates are entitled to all the information the patient can offer. The examiners will usually similarly instruct the patient to tell the candidates all they can.

3. A related but slightly different question is, ‘What do you see as the main problem with your health at the moment?’ Expect more than one problem!

4. Ask why the patient is in hospital this time (i.e. is he or she an inpatient or outpatient?) and, if relevant, the presenting symptoms when he or she was admitted. A number of patients are brought in specifically for the examination and will have no acute medical problems.

5. Ask early on what medications the patient is taking. A full list should be provided for you by the examination centre. This will give you valuable information about both current and past problems and is usually, but not always, helpful (Table 4.1).

Table 4.1

A medication list provided by a patient with extreme interest in her medical condition

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Although a list of medications is usually a big help, this one might cause anxiety for the examiners and candidates.

6. Ask the patient about any recent tests, again to obtain clues about the current problem.

7. If, as you probe, the patient stops talking, ask, ‘Anything else?’ and repeat as needed.

In the majority of long cases, the patient has a chronic illness about which he or she may be very well informed. It is sensible to make use of this knowledge, but remember the trap that patients may be biased in their opinions and give (inadvertently) false information. Be sceptical about patients’ opinions regarding their diagnoses and ask questions that will help verify what the patient has said. For example, a patient who says he has had five heart attacks, but has not been admitted to hospital for any of them, is probably mistaken. A candidate who merely repeats to the examiners what the patient has said without any attempt at interpretation does not come across as a sophisticated physician. Many experienced patients bring in a typed summary of their medical problems. The examiners have decided to tell patients to use these as an aide memoire for answering the candidates’ questions, but not to hand them over. Candidates should exercise scepticism when patients bring in large amounts of medical information about themselves. Some patients have an exaggerated interest in their health and there have been a few suspected Munchhausen patients might slip into the exams (Table 4.1). It is the sign of a mature candidate that he or she can manage ‘difficult’ patients.

Having established the main diagnosis early, confirm this with specific questioning. On finding symptoms not fitting the diagnosis, decide the likely possibilities and follow up with further questions. Never blindly believe the patient.

Next, enquire about other problems. Most long-case patients are chosen because they have multiple medical problems. An example might be an elderly woman with interstitial lung disease as her major presenting illness, who also has significant ischaemic heart disease and chronic kidney disease and peptic ulceration secondary to aspirin use. It is a terrible experience to discover another major illness only minutes before the end of the time. List all the important diseases chronologically and obtain full details about each one. Organise to present the most important (i.e. often the current) problem first, followed by the others in order of importance. Some healthy scepticism about the patient’s opinion of the diagnosis is usually warranted. A history of exotic previous illnesses without a history of appropriate investigations or treatment for such conditions should prompt a careful retaking of the history.

It is important to appreciate the great amount of detail the examiners will expect about the patient’s past history. A lot of time needs to be spent on this. Failing to uncover a medical problem from long ago that the examiners found when they saw the patient counts against the candidate. Remember that the patient’s history is often well rehearsed after the examiners and perhaps another candidate have taken it.

If the patient has an illness that can become suddenly severe or life-threatening – for example, asthma or insulin requiring diabetes – ask whether there is an action plan. That is, does the patient know what to do or whom to contact if he or she becomes suddenly worse? All patients should be asked about their immunisation status, including influenza, hepatitis A and B and pneumococcus.

Do not ever forget the social history. This is especially important because the examiners (and society) are keen to have caring specialists who are fully aware of the complete social environment of their patients. The examiners will expect great detail here as well. Always ask about:

• occupation – now and in the past

• adequacy of income – particularly if the patient is on a pension, can the patient afford medications and transport to appointments?

• current housing arrangements – e.g. renting, mortgage

• ability to cope and resilience at home and the quality of life if this is a chronic disease problem – the activities of daily living (ADLs) should be assessed

• stress points – are there problems in the patient’s life which make coping with the illness much more difficult, e.g. threatened loss of their driver’s licence

• depression – it is reasonable to ask patients if the illness or other problems have been associated with depression, loss of interest in life and even suicidal thoughts, but be tactful; also consider anxiety. Don’t miss post-traumatic stress disorder in a returned war veteran

• mobility – particularly the number of steps that need to be climbed at home and at work, and on which floor of the building the patient lives

• hobbies – e.g. contact with animals, chemicals or dusts

• marital status and number of children (from which partners)

• sexual problems – particularly ask about erectile dysfunction in men if indicated (e.g. patients with diabetes)

• end-of-life decisions – discussion of this may be appropriate if the patient has an incurable disease

• place of birth

• overseas travel in relationship to the illness.

A family history must also be taken. This sort of information is easy to obtain and fills in discussion time neatly, but disaster can threaten if the candidate does not know it. The most important aspects should be outlined in your initial presentation and the rest kept in reserve to be unleashed if the examiners show an interest.

There has been recent debate about the need for candidates to take a detailed sexual history. In reality this is only necessary if it is related directly to the patient’s medical problems, e.g. someone with HIV infection. It would not be usual for a doctor to take this type of history during a first consultation, except in these circumstances. If asked why you had not taken a more detailed sexual history a reasonable answer would be that it was not directly relevant and that your usual practice is to wait until you know the patient better before asking questions of this sort.

As you examine the patient, always ask when the examiners came, what parts they examined and whether any comments were made about the signs. One candidate was told by his patient that during a fundoscopic examination the examiner had said: ‘What an interesting Roth’s spot!’ However, this is no substitute for a thorough examination.

Even though you should spend most time on the relevant systems, remember that sometimes unexpected signs will crop up, such as a large breast mass, gross papilloedema or an abdominal mass. The examiners always have in front of them a list of the signs and have always gone to the trouble of checking that, in fact, these signs are present. You will be expected to have found all the important signs, so be thorough. Any equivocal findings should probably be ignored. Ask the proctor attendant for the results of the urinalysis and rectal examination; you are not expected to perform these personally. Also, don’t forget to take the patient’s blood pressure at some stage and check for a postural change, if at all relevant (e.g. diabetes mellitus).

Practise performing quick screening tests e.g. GALS (gait, arms, legs and spine (Ch 9) as a test of mobility, and have an approach to assessing diabetic patients for their possible vascular and neurological complications quickly.

At the end of the history-taking and physical examination, always ask the patient: ‘Is there anything else you think I should know?’ Amazingly important information is often volunteered at this point. Then ask yourself: ‘Could this be anything else?’, and ‘Can I tie all the multisystem problems into one disease?’ (usually you can’t in an older person, but this may be possible in a younger patient).

During the 20 minutes or so remaining, decide what type of case it is – that is, is it a treatment problem or a diagnostic problem, or both? Sort out the active from the inactive problems. Draft your introductory statement; for example, ‘I saw Mrs J Smith, a 30-year-old woman, who presents for the treatment problem of active rheumatoid arthritis and also for the diagnostic problem of jaundice’.

Next, mentally rehearse presenting the history and examination concisely and clearly. There is a tension between detail and brevity in the presentation of the patient. Experience and practice will help you get this right. Your concluding statement should reiterate the problems (in order of importance). It is usual to end the presentation by requests for relevant investigations. Always formulate a differential diagnosis, even if the history and examination lead to a definite diagnosis. Create a list of the findings on history and examination that support (or refute) the diagnoses considered. If a positive diagnosis cannot confidently be made, try to decide on the most likely diagnosis.

The discovery of a major problem with a particular long case (e.g. a patient with obvious dementia) shouldn’t lead to panic. By recognising the problem, fully examining the patient and having a plan of management (finding reversible causes, eliciting from relatives the social set-up, etc.), you will pass. One candidate who was faced with a demented patient in the long-case examination became angry and complained bitterly to his examiners. He failed.

Occasionally there are other difficulties, such as language problems (usually the candidate is supplied with an interpreter) or the patient becomes ill during the time (cardiac arrests have occurred). Be sure to inform the proctor attendant of any difficulties; people will go out of their way to be fair in such circumstances. The examiners will make a note of any such problems on their scoresheet, so that this can be taken into account by the executive later on. As the first question, the lead examiner will ask the candidate if there were any problems with the patient during the case. This is not the time to complain about the patient. The examiner will know if the patient was a difficult historian. However, if there were problems, such as late arrival of the patient or the patient’s need to leave the room a number of times to go to the toilet, this should be mentioned, but not dwelt upon.

The presentation

Your whole presentation to the examiners should take 10–12 minutes. Never go longer, ever! Leave out any irrelevant detail; padding the presentation never impresses. Avoid repetition; for example, mentioning various medications as a part of the history of a particular system and then later as part of a long general list. Try not to use the brand names of drugs.

The examiners are only human too: sometimes they are hungry, tired or just bored after previous presentations (particularly if yours is the last long case of the afternoon). Show interest and enthusiasm while speaking. Think of yourself as a news reader and speak at a speed that allows the examiners to keep up and take notes. Do not read your notes in a monotone. The notes are meant to be a memory aid. Break up the pace and include a pregnant pause after you make an important point (for emphasis).

Ideally, the long case should be a discussion between consultants, with the candidate being a respectful junior colleague. The examiners only rarely interrupt during the presentation. If your presentation is taking too long and there will not be time for discussion you will usually be interrupted and asked to summarise. One should aim to have finished presenting the history in less than 12 minutes.

Most examiners expect the candidate to finish their presentation with a list of the main problems they think should be discussed in order of importance. It is useful to ask the patient what he or she thinks is the most important problem with his or her health at the moment and put that close to or at the top of the list of problems, even if it is not the most interesting medical problem.

It is likely that the examiners will want to discuss the patient’s active problems. They will almost always want to talk about the problem the patient sees as most important. These should be the areas of management that you are best prepared for. It is very unsatisfactory for examiners to feel that they have not been told all the major problems, and what the management plan for each problem is, by the end of the discussion. At the end of your presentation, and before discussion of management, the lead examiner may ask some questions to clarify aspects of the history or examination findings. This should be no cause for alarm. After this, you are usually given the opportunity to outline a plan of management or the examiners may ask specific questions. Examining styles differ, but you should strive to direct the discussion tactfully. Being allowed to do this is usually a good sign, but not being allowed to control the discussion is not necessarily a bad sign. Some candidates appear to think that if they speak quickly and loudly enough they may prevent the examiners from asking any questions. This strategy does not work. The exam is meant to be a discussion and if the examiners cannot ask questions the candidate cannot score marks.

When appropriate, ask for one or two important investigations relevant to the problems, rather than rattling off a rote list of routine tests. Examiners find a long list irritating and consider it a sign of an immature approach. A reason should be given for ordering every test. For a diagnostic problem it may be useful to ask for the results of previous investigations. Any mentioned test may have to be discussed in detail with the examiners. Sometimes the examiners will not give you the results of a test (they may not have it available), but merely ask how it would help you. We suggest that you write down the results you are told (it is embarrassing to have to ask for the figures to be repeated). Don’t ignore any information that is given; for example, if the haemoglobin value is normal, comment on this and explain how it helps. Many examiners will have underlined or marked the relevant results from a printed pathology or biochemistry report. This is to avoid wasting time as a candidate wades through a series of irrelevant results. Concentrate on the marked results. Remember not to touch X-ray films or criticise the quality of the material shown. Pathological specimens are not shown in the clinical examinations.

Always prepare answers to the obvious lines of question and try to think like a consultant physician who is in charge of the patient’s care (and hypothesise that the patient is a close relative of the examiner!). If there is a diagnostic dilemma, consider the tests you want and how positive and negative results will support or refute your proposed diagnoses. In a management case, prepare an outline of the suggested treatment and be able to justify it. A good approach to management if the patient is an inpatient is to ask yourself, ‘What steps will be required to get this patient home?’ Always set management goals for all key therapeutic interventions. The examiners may ask about theoretical aspects of the condition. Most often, they will concentrate on the testing of factual knowledge in areas that are necessary for the formulation of adequate management decisions or interpretation of test results. You should think about these areas beforehand. Always consider whether the patient’s current treatment is justified and whether the diagnosis previously made is consistent with the history and examination; it may not be. Do not be afraid to contradict the current management in a restrained way, if there is clear justification.

A common series of questions for many long cases involving chronic diseases includes aspects of how you would discuss the illness and the prognosis with the patient. The examiners might ask: ‘What would you tell Mrs Smith about her prognosis and likely future treatment?’ and ‘What would you advise her about the safety of future pregnancies?’

The examiners will not usually ask hypothetical questions unrelated to the patient being discussed. If you are answering well, the line of questioning may change or the depth may become overwhelming. Do notbe frightened to say, in the latter situation, ‘I don’t know’, when asked a very difficult question. Obvious wild guesses will be detrimental. If the examiner persists in asking a question, it usually means he or she is trying to establish a basic fact. Talk sensibly around the topic – often a supplementary question will result in recall of the appropriate information. With an especially difficult issue it is reasonable to say you would consult the literature or an appropriate sub-specialist for advice. Remember that examiners are instructed to avoid making snap judgments or failing candidates because of one small mistake. The best examiners will not labour a point. If it is clear you do not know the answer they will move on to another series of questions. This does not mean you have failed, but rather gives you the opportunity to gain marks elsewhere.

You must be able to discuss sensibly anything that you mention in a viva, so don’t casually allude to rare diseases that you know nothing about (e.g. kala-azar as a cause of massive splenomegaly).

The long case rationale

The long case is a test of the candidate’s ability at history-taking, physical examination, interpretation of findings and construction of a diagnosis (and differential diagnosis), and approach to management (investigation and treatment). Important and common long cases are presented in some detail in the next chapters. The list in Table 4.2 is not exhaustive, but gives an idea of the range of possible cases. Most (but not all) are discussed in Chapters 513. Some other relevant aspects are dealt with in Chapter 16. These cases are presented as single problems but most patients will have a combination of problems. Some problems tend to occur together.

Table 4.2

Common long cases

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It would be unusual not to see at least one type 2 patient with diabetes on the examination day. These patients are often obese and have diabetic complications and problems related to their obesity such as vascular disease or arthritis. A common question to be asked about such patients would be fitness for surgery such as for a joint replacement. Another likely case is a transplant patient. Transplant patients havemany similar problems as well as the specific issues related to their particular organ failure and original illness. For example, a kidney and pancreas transplant patient may have complications of previous diabetes. It is well worth making an effort to see many patients of this type and have an approach worked out for their management.

Candidates are often very well prepared for common types of long cases and are able to produce a formulaic response to a trigger word such as diabetes or transplant. The examiners are then given a rote list instead of management directed at the particular patient. It is important always to relate these management lists to the actual patient and adapt them as required. Such an approach reflects the maturity expected at this level.

Another common problem faced by the examiners is the excessively detailed social history which takes up much of the presentation. Relevant social problems should be noted and candidates, if asked, should be able to provide more detail and discuss the problems sensibly, but attempting to replace the more difficult medical aspects of the patient’s care with this will not lead to a successful long case – we anticipate the examiners are on to it!

Types of long case

The cases in Chapters 513 are written as a guide to dealing with the long-case examination and are not meant to replace textbook descriptions. To pass, you must really know and understand your general medicine, be able to take a great history, examine accurately, and maturely synthesise all the data. Remember that usually several problems occur in the one case. A patient with an unusual diagnosis will often have one or more common problems as well.

The examiners will often ask whether you would like the results of appropriate investigations. Be prepared to interpret any results you have asked for. Electrocardiograms (ECGs), chest X-rays, and computed tomography (CT) and magnetic resonance imaging (MRI) scans may be shown to candidates. Echocardiograms are not usually shown to candidates, but you are expected to be able to interpret echocardiography reports. Some common examples are included in Chapters 513 and also in Chapter 16. At the end of each report is a comment that gives an idea of the sort of interpretation expected from candidates.

The key to passing any exam is obviously providing the examiners with what they want. Candidates have plenty of opportunity to find out what examiners want. Practice cases with examiners and senior registrars; the stories (sometimes exaggerated) of previous candidates and information from the College are all readily available these days.

If you can think like an examiner then you can give them exactly what they want. In essence what they want is that you should think like a physician. The College exam is quite successful at producing people who think like physicians. Physicians from all internal medicine specialties have had a common training experience and this makes communication between them easier.

There is a list of basic skills and qualities that an examiner wants you to establish from your long-case presentation.

1. Are you safe?

2. Do you know what you are doing and what your limitations are?

3. If you go on to become a cardiac electrophysiologist, starting next week, do you know enough about say, thyrotoxicosis, to cope with it, with help if necessary?

4. Have you developed a competent approach to the patient who has problems involving many sub-specialties?

5. Have you an approach to the patient which is sympathetic and practical? This means knowing at least enough about a patient’s non-medical circumstances to understand what might affect his or her ability to have treatment and how different treatments might affect the patient; for example, financially because of a particular occupation.

6. Have you recognised the problem the patient thinks is most important?

These simple principles are worth keeping in mind as you interview and examine your long-case patient. They should help you work out what the examiners will consider important and what sorts of questions they are likely to ask.