Clinical Reasoning Skills

How to do a Long Case

Bernard Champion
Clinical Studies Coordinator
Sydney Medical Program

The Long and Short of it.

PROS
Aligns learning & assessment
Validity
Complex skills
Adaptable to different levels

CONS
Less reliability
Case specificity
Examiner variability
Time & resource avid

Traditional

Anachronistic

General Considerations
A Long Case is not purely a test of
knowledge.. rather it is a test of
ability to collect, collate &
communicate complex information in a
clear, logical and concise manner

Good technique is crucial - similar

process whether Stage 3 FRACP

Long Case Timing & Assessment

60 minutes

History &
examination

30 min history
15 min exam
Aim finish 45 minutes
Case written up by 1 hour

20 minutes

Writing/preparation

Prepare discussion

20 minutes

Examiners

Case 10 minutes

5 minutes

Marking

Feedback if formative

Marking

Formative Long Case Marking Sheet.pdf

1 History
2 Examination
3 Summary & Problem List

Need 2 of 3 competent

4 Differential Diagnoses & Investigation

5 Management
6 Impact of Illness on patient and Family
Need 2 of 3 competent

5 point grading system:

Poor: short of standard: expected standard: better than expected: much better than expected

Case grading: straightforward v moderate v difficult

Suggested Long Case Structure

1.
2.
3.
4.
5.
6.
7.

Introduction
Presenting Problem
History of Presenting Illness
Past Medical History
Medication List & Allergies
Social History (Pyschosocial; Functional; Family; D&A)
Examination

8.
9.

Summary
Discussion (Issue List; DDs; Investigations; Management)

Introduction
Crucial initial impression!
Catch the examiners attention and show you
are on the case!
Mrs Smith is a 75 year old woman living
independently who presents to hospital with
progressive onset of shortness of breath and leg
swelling over 1 week on a background of known
ischemic cardiomyopathy, CCF, smoking-related
COPD and type 2 diabetes on insulin

Presenting Problem
Why did you come to hospital / here today?
May not be an acute problem e.g. Outpatient
Mrs Smith is an outpatient who presents for the
purpose of the long case exam today.
Pt interpretation of Presenting Problem may be
different to yours
Some pts genuinely do not know!
Probe e.g. What have they done for you since you came to
hospital?

History of Presenting Illness

Cover:

Symptoms
Onset & timing
Relevant + or Relevant risk factors

NB: some cases HPI may

merge into start of PMH
e.g. SOB & CCF/IHD

Be thorough
Ask about
investigations & results
Ask about treatments
received or pending

Dont requote mis-sense

Past Medical History

Try to list in order of:

1.
2.
3.

Relevance to HPI
Activity
Gravity

Develop pro-formas for

common conditions:

Diabetes
Heart Failure
IHD
COPD
Asthma
CFR/dialysis
Chronic arthritis
OP
Steroid therapy
Falls
Obesity

Past Medical History

When diagnosed?
How diagnosed?
Complications?
Past treatments?
Any treatment
complications?
Functional status or
limitations; QOL

Smoking related COPD

Dx 2005 pneumonia
RFTs & CXR

IL B2 agonist / steroids
Oral steroids 2x/ year
Vaccinations UTD
No home O2
No ICU / intubation
ET when well approx.
100m
Independent in ADLs

Medication List
Pts can misunderstand reason for a medication
I take Lipitor for my blood pressure

Use generic names

Dont obsess over doses & timing
Group medications by conditions they treat ( can list
meds in HPI & PMH)
Correlate Medication List back to HPI and PMH to look for
omissions, duplications and interactions
I see you have had a heart attack in the past do you take
aspirin to thin your blood?

NB: Long case exam situation vs Ideal Practice

Social history *
Psychosocial
Carers, supports, services
QOL, activities, hobbies
mood /depression

Functional
ADLs
Physical residence & financial circumstances
Falls *

Family History
Most relevant

D&A
alcohol, smoking*, other*

Examination
1.
2.
3.
4.

General inspection comment

Obs/vitals
Involved system first
Other systems by relevance
Try to highlight key relevant + or featues rather
than list absence or presence of every individual sign
*(RTC)

Develop a pro-forma

Summary
Crucial wake up examiners!
Parallels Introductionm + extra
information (e.g. Exam features +/- your
interpretations e.g. diagnosis
In summary Mrs Smith is a 75 year old widow, living
independently, with background of known IHD/CCF,
smoking-related COPD and T2D on insulin. She presents
with 1 week of progressive dyspnea and oedema due to
exacerbation of CCF with a presumed antecedent upper
respiratory tract infection. History and examination are
consistent with CCF.

Problem List
Can be tricky
Try to continue on from summary
(if not interrupted examiner lost/distracted or you are doing well!)

Aim ~ 4 key issues

Try to group or link related issues
Your issues & order may be different to pts!

Problem List
In summary Mrs Smith is a 75 year old lady living independently who
present with..
The key issues in this lady are:
1. Confirmation of diagnosis & ongoing management of her CCF
2. Rehabilitation and institution of support for return to independent living
3. Optimizing her longer term cardiorespiratory status including
management of her COPD and vascular risk factors, including DM, Lipids &
BP
4. A painful ingrown toenail on her left foot

I would to like to discuss each of these in turn. In regards to her

CCF..

Differential Diagnoses
Aim for 3 - 4 major ones
List in order of relevance and likelihood
The differential diagnosis of Mrs Smiths
SOB would include:

Silent cardiac ischemia

Cardiac arrythmia
Respiratory infection
Pulmonary embolus
Anemia

Investigations
Order in order that are likely to occur in
practice e.g. FBC, Trop, ECG before an angiogram!
Be able to justify what you are ordering
I would order a full blood count looking for
evidence of infection or anemia

Dont ask for a multitude of results! You will get

bogged down

Management
Aspirational!
Less rigorous at your level
Need to know basic Mx of key conditions*
Remember the Rule of 4
If you get this far in your presentation having
covered everything else you are probably
dong well

General
NEVER LIE about omissions!!! Damage control
due to my exam nerves I have forgotten to ask about
smoking history .. This is something I would
normally ask and it is very important in this case

Be clever about weakness; no-one knows all!

Im not sure but I would consult the literature or ask
a colleague who works in that area.

The Presentation
Poor technique can negate excellent presentations
look happy - this exam is fun!

speak clearly & make eye contact

have a familiar system of cards /paper/ folder
practice positive body language & posture
Answer questions! Evasion is obvious! Ask for clarification if unsure

Dont argue!
Examiners are ALWAYS right (even when wrong!)
Examiner not there to trick you; dont reverse psychologize!
Be alert for clues /leads (should not occur but may)

The Examiners
See patient before you and
agreed on a list of key signs,
issues and questions
Calibrated ;criteria marking
Independent marking the
consensus
Should not examine own
specialty, but might!
Do not be put off by not
knowing something it may
not be important or the
examiners may be seeking ot
extend you because you are
doing well!

The Patient
Show appreciation
Dont complain! - if sick, confused, uncooperative,
unreliable do your best! Examiners know; you can subtly
point out Mrs Smith was uncertain about some
aspects of her medical history.
Rare diseases; DONT PANIC! Pt may know enough to
pass learn from them
May be a current/recent inpatient with acute issues but
many are outpatients with chronic stable issues
Remind them to tell you everything re their medical history
Check medical bracelets /charts /fluids /medical alert signs
Ask if you missed anything examiners asked!!!

 Questions?