Long Case Exam Structure
Long case constitute a quarter (25%) of the total mark (theory + clinical). As you may have known, it is crucial to pass the long case to be considered as passing the part II exam. The minimal passing mark is 45%.
As this is a exit exam, you are expected to perform like a specialist in terms of your presentation skills. The thinking process has to be mature and a sound plan is expected from you. You need to be analytical in your though process. The cases included in the examination is usually a long and complicated management issue. Examples like long-standing diabetes with target organ damage, issues with adherence and hypoglycaemia, hypertension and disability at work caused by his poor eyesight due to PDR. Otherwise, you may get a case with diagnostic problem like rare combo disorders such as MEN 2a, Miller Fisher variant. Most often its a mixture of both diagnostic and management problems.
You will be given 1 hour with the patient. History taking, clinical examination, analysis of the case and formulation of a sound plan is expected during this one hour. There will be a 10 minutes gap to gather your thoughts and organizing your words. This is followed by 30 minutes of discussion with 2 examiners. During this time, you are expected to present your case and the examiners may bring you to the patient to elicit some signs. Then the discussion moves on to the management of patient.
Truth be told, time flies during the exam. I will share on how to approach and divide your timing during the exam in the following section.
Before The Exam: How To Prepare?
There is no standard textbook. I guess this is due to the vast diversity of cases that may occur in exam. However, there is always a pattern to be spotted. There are main diseases in each subspecialty that need to be covered before going for the exam. Examples are diabetes mellitus and its complications, SLE, HIV etc. One need to prepare for the diagnosis and its differentials, investigation and a sound plan for the patient. The book I used was "Mastering the Medical Long case 2e" by S Rohan.
Apart from the clinical aspect, one need to go in depth with patient's social issues. How does the patient cope with the disease, and who provides support for the patients? Assessment of a person's functional status gives an overview to the implication of disease to the patient. The idea is to see patients as a whole and practice holistic approach.
Try to practice long case as if you are taking the exam the next minute. Limit yourself to 1 hour. Divide the timing into 3 blocks of 20 minutes each. First 20 mins is crucial to get the targeted history and the presenting complaint in depth. Relevant past history should be obtained. The next block is the physical examination. Do a relevant systemic examination according to history. You can still ask the patient and clarify any doubts. Lastly which is most important is to organized the thought and prepare your opening statement. If the history is longer than anticipated, you can change the block into 30 minutes of history, 10 minutes of examination and 20 minutes of structuring your case. In short, non of the component can be neglected, especially the last component.
During The Exam
Patient, to me, is the most important factor. You need to establish rapport as soon as possible with the patient. Convinced them this is a professional exam and no information shall be withheld and to put forward the medication list up front. This is to avoid unnecessary surprises towards the end of clerking. If there is a surrogate around, try to involve them as well.
Leave the opening statement to the last. You need to gain as much picture into the case, then only you can come out with a good summary.
For the history segment, try to write each issues in separate pages. Pay as much attentions to the chief complaints, as this is most likely to be scrutinized during the presentation. Try to move away of presenting symptoms, instead analyze the collection of symptoms and give a reasonable differentials. Examples:
a. "Mr Jude presented with 3 weeks history of shortness of breath especially on exposure on dust. Symptoms worsen during working days and wane during off days."
b. "Mr Jude has symptoms suggestive of occupational asthma as evidenced by worsening shortness of breath at work and better during off days"
During The Exam
Patient, to me, is the most important factor. You need to establish rapport as soon as possible with the patient. Convinced them this is a professional exam and no information shall be withheld and to put forward the medication list up front. This is to avoid unnecessary surprises towards the end of clerking. If there is a surrogate around, try to involve them as well.
Leave the opening statement to the last. You need to gain as much picture into the case, then only you can come out with a good summary.
For the history segment, try to write each issues in separate pages. Pay as much attentions to the chief complaints, as this is most likely to be scrutinized during the presentation. Try to move away of presenting symptoms, instead analyze the collection of symptoms and give a reasonable differentials. Examples:
a. "Mr Jude presented with 3 weeks history of shortness of breath especially on exposure on dust. Symptoms worsen during working days and wane during off days."
b. "Mr Jude has symptoms suggestive of occupational asthma as evidenced by worsening shortness of breath at work and better during off days"
The first examples history as its selling point. Technically it is not wrong, but it feels like the candidate did not put effort to analyze the case. The latter example puts a reasonable differential up front and followed with the supporting history. This is the preferred way to sell your case as it exhibit maturity and confidence.
Do not skimp on the detail. You will be surprised the amount of information they (the examiners) has in their answer script. As the script is based on not only clerking, but also the investigation and intervention done on the patient, it is crucial to get as much details as possible. It's rather embarrassing for the moment of silent when they try to extract the information that you don't have and trying to confabulate doesn't help as well. One useful tip is try to get the detail picture of admission or visit of patient into the examination hospital. Usually the detail of admission to the respective hospital will be most detailed and will be asked the most.
Examination of the patient should be done in systematic manner and prioritize the systems that the patient complains. Do not forget the vital signs, urine dipstick, body weight and blood glucose if relevant. As the examiner may ask you to demonstrate the finding later, make sure get the relevant positive and negative signs ready.
The last part of the preparation is the summary of case, construct your long case into a logical and interesting case. You may want to go back to the main history and add on any missed points. More importantly you need to construct differential diagnosis, investigations and formulate a plan for the patient. After all is done, take time to construct the opening statement.
Opening statement is a powerful and catchy phrase that contains all the crucial points of your case, yet not too lengthy. If it is too short, it will not give the examiner a whole picture of the case. If it is too lengthy, it will bore down the examiners. Starting with a weak opening statement will cost you dearly in the exam. To make the matter worse, there is no standardized way to make a good opening statement. Let me show you an example.
Ms Janet, is a 36 years old clerk from Puchong with diagnostic and management issues of SLE complicated with lupus nephritis now in end-stage renal disease. Other inactive problems such as exogenous Cushing's syndrome secondary to prednisolone and osteoporosis. She is also having depression and in financial constraints.
From the examples above, it gave the examiners a snippet of the case of SLE complicated with ESRD due to lupus nephritis. She is also depressed and having financial difficulties. Putting in a social issues makes you look holistic and concerns about patient psychosocial aspects. Always identify 1-2 of the most important part to include in the opening statement and in the clerking later.
Put Up A Good Show
After the bell rang, you have approximately 10 minutes till the examiners call you in. Use the time to rehearse your case, especially the opening statement. Try to picture it like a movie and see the flow of the history. You are given 30 minutes. Present like a salesman, convince the examiners to buy your story. Eye contact is very important. There will be 2 examiners and try to give them both equal attentions. They may stop you intermittently to clarify your case.
If they are satisfied with your case, they will bring you to bedside to demonstrate the findings.
Next part of the discussion is about investigation and management. Time is scarce and investigation must be focused to the case. There may be a scan or radiograph that need you to interpret.
The tip is to be calm and engaging to the examiners. The examiners can feel your knowledge and understanding of the case by looking at your non-verbal cues. In no time at all, the examination will be over. If you did badly, try not to carry forward any feelings ito the next section as you may still have a chance to redeem yourself.
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