Approach to the Long Case

Approach to the Long Case - Victor Lee

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Time:
35 mins with patient
5 mins break
20 mins with two examiners

Patient: Inpatient or outpatient, typically multisystem illness

Examiners: See patient blind to ascertain level of difficulty

Equipment: Blank paper & clipboard; candidate's equipment as for short case, no electronic aids

Core competencies:
Clinical history presented in a systematic & logical fashion
Establish the correct facts from a clinical history
Focussed & systematic physical examination
Establish correct findings on physical examination
Suggest appropriate investigations in a logical sequence (to establish or rule out relevant diagnoses)
Postulate a relevant diagnosis (or diagnoses) including differential diagnoses with relevant weightings
Establish appropriate acute management strategies for the specific case
Communicate with senior colleagues in a clear, well paced fashion

Presentation (approx. 12 mins):
Introductory synopsis – diagnostic and/or management issues
HOPC
PMH
SHx
Meds & allergies (ask for chart)
Systematic review
Physical examination findings
Summary of active & inactive problems
Investigations in ED (prioritise)
Management in ED (prioritise)

Examiners discussion (approx. 8 mins) – interpretation of results & current or future treatment
Purpose:
How you perform during a usual day at work
How you identify and manage what is common & commonly deadly
How you attend to the 3Cs – condition, cause & complications
How you demonstrate practice at the level expected from a FACEM

Tips:
Practice long case with patients you see at work – remember 35 min time constraint
Ask patient if inpatient or outpatientIf outpatient ask about most recent acute presentation or active problem
Focus on ED presentation – as if you had just picked this patient up
Go ahead and ask for diagnosis – this is happens in real life in ED
No harm asking, "what else did examiners ask you?
Present as if discussing with colleagues
Discuss consultant level issues

References:
Australasian College for Emergency Medicine. Training & Examination Handbook 2009.Wilkes G., Pierce B., Foot C. & Ting J. (2010). Examination Emergency Medicine: A Guide to the ACEM Fellowship Examination. Churchill Livingstone.



Approach to the Long Case - James Taylor, April 2008

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History, Page 1 & 2 (15 minutes)
Patient name and age
Residence in relation to hospital, eg. rural (shows perspective)
Main problems in the setting of limited or relevant past history (four ordered priorities)
Presenting complaint, detailed including hospital management
Past history (with emphasis on relevant aspects)
Medications (including a drug history, side effects, allergies)
Family history (including early deaths)
"Social" history (supports, occupation, cigarettes, income, alcohol, lifestyle)
Systems review (cardiovascular, respiratory, gastrointestinal, nervous, endocrine)
Exercise tolerance, hobbies and ability to travel
"What tests have you had recently?"
"Did the previous doctor comment on anything else in particular?"

Examination, Page 3 (15 minutes)
Vital signs (BP, temperature, pulse, saturation)
Cardiovascular system exam
Respiratory system exam
Focussed neurological system exam
GIT system exam
Emphasis on relevant positives and negatives to the main problems

Summary, Page 4 (5 minutes)
This will double as the opening statement
Ordered problem list (no more than 4, begin building during interview)
Differential diagnoses for the main problemsInvestigations (given in order of availability, justifying each) - bedside, pathology, imaging
Management plan - treatment, referral, disposition and other options
Concluding statement