Long Case Structure | posttakeround

How To Do A Long Case (The Long Case Structure)

Overview

The purpose of the long case is not to just gather information and present it back in as a list, but rather to synthesise information and offer a broader perspective about the patient and his/her care – “the bigger picture”. Always take a step back when thinking about the important factors in a particular case.

Keeping that in mind, the next most important element to the long case is having a clear structure for collecting and presenting information. Many different people will give you difference advice. There are multiple ways to do it, and so you will need to synthesize the advice and different strategies you are given and come up with your own set structure that you will follow.

The following is how I approached it. I did have set structure, but this had to be adapted for certain conditions (e.g. SLE, allogeneic transplant) as not everything fits neatly into the same ‘DRPIMCO’ etc. or equivalent. I wrote out structures for the common conditions (many of which ultimately shared the same structure), which also helped me learn about the pertinent clinical knowledge for these. I would then practice writing this out at home, imaging different hypothetical cases and how I would structure and present these. I found this very helpful when it came to doing real cases.

A few final comments:

The synthesis of clinical information should also come across in your presentation. This also helps with time management when presenting.
- For example, don’t always just say ‘he was diagnosed with this…his risk factors were this…his presentation was this….” even though you have may collected information like this; synthesise it and present it medically
You should provide your medical overlay to what the patient is telling you. As said, it is not just an information gathering exercise. For example, if the patient cannot tell you the results of a particular test, or is very unfamiliar with key and crucial elements of their care, then you can comment on this (I will expand on this separately)
Often, it is not about the medicine, particularly in complex medical cases with conditions managed by sub-specialists (such as many of the haematological conditions). You are not expected to be specialists (and your examiners won’t know about niche conditions as well). In these cases, you should view your long case and role as being their general physician, coordinating the key elements of their care. Again, take a holistic view – what are they key elements important to this patient and affecting this patient’s health? For someone with a complex subspeciality condition, this could be that they live 50 minutes from the hospital, and can’t drive to their appointments, and don’t know how to use telehealth, or perhaps it’s their cardiovascular risk which isn’t addressed etc.
The order you present issues should be logical.
- This will vary on the case, and I cannot be prescriptive in how to do this. I will provide a separate example about someone with ESKD whose eligibility for transplantation is affected by obesity; the flow was from ESKD, then obesity as an issue, then cardiovascular complications such as IHD.
- A complication of a disease or treatment may be a dominant issue in itself (for example cirrhosis as a dominant active issue from chronic GVHD following transplant for lymphoma in remission). In this setting, it may be appropriate to quickly summarise the lymphoma and transplant presentation, signpost the GVHD within this, and then present cirrhosis as the discrete dominant issue. This requires practice.

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Overview of broad sections

Below is the list of sections I collected and presented. I will expand on each of these individually:

Introduction
Active issues (including what I term ‘stable’ active issues versus a symptom presentation – I will expand below)
Inactive issues
Preventative health
General health items not to miss
Medications and allergies
Social History
Future planning
Examination
Closing statement and issues list

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Introduction:

There is no absolute fixed way to do this, and I cannot be too prescriptive. You want to keep it snappy and concise.

Some general advice, which should be adapted:

20-30 seconds
Avoid long lists (i.e. PHx is....)
Incorporate important social factors into description and then outline the most important aspect of their case
Give a sense of prognosis or insight going forward

Example 1

I had the pleasure of meeting Harry, an 82-widower undergoing an inpatient trial of IVIG for a treatment of a peripheral neuropathy likely due to an autoimmune process. His history is also significant for macrovascular disease and severe COPD. Harry’s main concern at the moment are due to his neuropathy that he won’t be as mobile that will be worsened by his persistent breathing problems. Harry is vulnerable to deterioration from his multiple medical condition and lacks insight to his overall prognosis. He is motivated to address to these and is well supported by a large family network.

Example 2

I had the pleasure of reviewing Rachel, a 55-year-old payroll assistant from home with her adopted mother, who faces the ongoing chronic burden of dialysis dependent end stage kidney disease. She is hopeful for a renal transplantation to restore her quality of life. However, I am deeply concerned for her eligibility in the context of her obesity, which is further complicated by ischaemic heart disease and osteoarthritis. Whilst Rachel is motivated to lose weight, she feels unsupported in this process, and it will be crucial we use a multi-disciplinary approach to address this.

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Active medical issues

It is important to have a structure for collecting and presenting information here. I personally found the widely used DRPIMCO relatively inadequate for a logical flow of information.

As you will see in my separate document on specific conditions, this structure will be adapted depending on the specific condition (for example solid organ and stem cell transplants).

In terms of the ‘active’ issues presentation, this will generally involve presenting discrete ‘active conditions’ (such as heart failure, ESKD, diffuse large B-cell lymphoma, osteoarthritis). This is most likely what you will get in the real exam (as opposed to an acute inpatient presentation). Occasionally it will also involve presenting sections on an undifferentiated symptom (such as dyspnea FI). From my perspective, the presentation of undifferentiated symptoms is slightly different, and ‘DRPRIMCOO’ or whatever you use for specific conditions does not generally work for symptom presentation.

Active conditions

My structure below is for what I term ‘stable’ active conditions – i.e. outpatients, which is what most of the patients on the day of exam will be.

Diagnostic section:

The sections below should then by synthesized in the presentation and conveyed in a flowing logical way.

Diagnosis: when, where and by whom
Risk factors
Presentation
Investigations to diagnose
- TESTS:
  - To diagnose, Exclude other DDx/aetiology, Severity, Treatment baselines, Suspected complications
  - I use TESTS as a framework, but do not need to list all

Treatment and progress and current status section:

Neatly synthesise the following when presenting, describing the evolution of condition over time and discuss current treatment and current status. The exact order may vary on the condition

Initial management
Progress and pattern of disease over time
Current management
Current status of disease (e.g. status of symptoms, latest HbA1c, TTE result etc.)

Complications

Complications
- Of disease
- Of treatment

Forward planning and future outlook sections:

This is a bit of a fluid section to capture some of the miscellaneous social and practical aspects, which can also be captured in subsequent sections below (social history, preventative health, future planning). If it works well, you can incorporate into the presentation of the issue itself. How much to include within the presentation of the individual condition may vary.

Impact on life
- This can be discussed here if relevant, or alternatively can be captured in the social history
Future outlook and forward planning
- Prognosis + future plan
- Patient understanding and insight
- Follow up plan + screening
  - E.g. who is the primary doctor for this condition, what is the follow up, do they understand their follow up
  - E.g. what follow up screening tests do they need?
- Example 1
  - Mr X has good insight into the need for ongoing aggressive risk-factor modification and cardiology follow-up, although cannot tell me his HbA1c, BP or recent lipids (So you're highlighting what he would optimise). He is amenable to further invasive cardiac interventions or investigations if required in the future.
- Example 2
  - Mr X has not seen his cardiologist in 2 years, cannot tell me his ECHO finding and is unaware of his BP, lipids and HbA1c. I am concerned a lack of follow-up and aggressive risk management will lead to deterioration of his IHD. Mr X cited cost as his main barrier to accessing his cardiologist, which we will discuss more in his social Hx.

Symptom presentation

As highlighted above, presentation of undifferentiated symptoms is slightly different to discussing discrete conditions.

Structure

Framing statement
Describe symptoms
- Positive findings
- Associated findings
- Pertinent negatives
Relevant co-morbidities and risk factors
Specific investigations (in particular since the change or onset of symptom)
Specific management (in particular since the change or onset of symptom)
Framing question to segway to disease discussion

Example:

First issue is multi-factorial SOB
Symptoms
- ET of 30 metres, from 100 metres six months ago
- Associated with sputum productive, orthopnea and PND
- Pertinent negatives include chest pain, fevers/rigors, or constitutional symptoms of LOW, LOA and night sweats
This occurs in the context of multiple known cardiorespiratory medical co-morbidities including COPD, HF, and pHTN. He also has risk factors for OSA with obesity, and deconditioning from multiple medical conditions
He has not had any new specific investigations since the deterioration in his symptoms.
- Or...Since the deterioration in his symptoms, he has had a CXR 3 months ago, which was non-diagnostic, a TTE with an EF of 42%, and RFTs showing a worsening obstructive deficit, although he could not quantify this. He is unaware of his haemoglobin count, and has not had any higher resolution imaging, or sleep study.
His management so far seems to be targeted towards his HF and COPD, and so although there is a broad differential, so far it seems it has been largely attributed to these, and I would like to discuss each of these in turn.
Then go onto to discuss associated conditions using DRPRIMCO or my structure above (In regards to his HF….)

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Inactive problems

Do not spend a lot of time on this section if it is not relevant to their active ‘big picture’

Example

The only other conditions for Harry is gout, for which he is well controlled on allopurinol.

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Preventative health

Vaccines
Malignancy screening (PAP/HPV, FOBT, mammogram, skin checks) - put in main issues of relevant to patient (e.g. transplant)

Example:

His is up to date with his ____ vaccines but has not had his ___. He has had age-appropriate malignancy screening for bowel/prostate/breast/cervical. He has had regular skin checks with his GP/dermatologist.

General health

Items not to miss (FOOODIIE P)
- Falls
- Osteoporosis
- Obesity
- OSA
- Depression
- Incontinence
- Insomnia
- Erectile dysfunction and sexual activity
- Pain

Example

On general health screening, Harry reports _____. He reports no issue with mood. He denies erectile dysfunction and is/is not sexually active. He eats a healthy diet.

Example

On general health screening, Harry reports insomnia worsened by his neuropathic pain for which he takes melatonin, which only partly helps with sleep initiation. He does not have osteoporosis based on a recent DEXA scan, but does take calcium and vitamin D supplementation, likely in the setting of recent steroid use for prevention. Harry is not sexually active. He reports no issues with his mood, and he eats a healthy diet.

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Medications (those not mentioned, pill burden, compliance and understanding of, pill aids, allergies, vaccinations)

List any unaccounted medications
Discrepancies
AAA
1. Allergies
2. Aids (dosette box, Webster pack, carer)
3. Adherence

All these points should be listed for every case. If a patient struggles with their own medications or doesn’t understand them, or struggles to pick them up, or access them from pharmacy etc, then this is prime material for the long case.

Example

I have accounted for all of Harry’s medications / the only medications unaccounted for are ____. He manages his own medications / uses an aid and is adherent. He is allergic to ___ for which he gets a ____.

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Social history

Age
Born
Family
Education/Work
I like doing a global statement here on what they were like prior to their illness; global statement to highlight their life and personality and then can lead into nicely to discussing their current social situation and the impact it has had on their life.
Living situation:
Mobility/aids:
Home modifications:
ADLs:
Main support/home care packages/NDIS:
Driving:
Current work:
Finances:
Hobbies:
Social network:
Sex/intimacy:
Drinking and smoking if not already mentioned:
Mood/satisfaction/self-esteem
Religion
Global statement to show the significance of situation and your concern

Example

In terms of her social history, Rachel was born in Melbourne and adopted at birth. She has two adopted sisters. Her adopted father has passed away. She has no desire to meet her biological family. She describes a ‘normal’ childhood, and went on to finish tertiary education, before taking various administrative payroll jobs.

Global statement to give a nice overview that you get the big picture: Prior to the progression of her kidney disease, she describes herself as an outgoing, social, hard-working woman. She lived by herself, had various social groups, and liked to go travelling each year. It is therefore clear that her medical conditions have had a devastating impact on her livelihood.

Living, mobility, ADLs: She has since moved in with her 80-year-old mother in a one-story unit, largely due to the extra support. There are no home modifications, and she requires no mobility aids. Rachel can be independent in her ADLs, but given her schedule, relies on her mother to help with domestic duties such as cooking and cleaning.

Main support: Her mother is her main support. She states her mother is in good health, but ‘slowing down’. There are no formal council or NDIS supports. She does not currently have a partner.

Then list the others in a narrative way, which can be very brief if not particularly relevant. For example, with finances, if it is not an issue, I simply say ‘he is financially secure’.

Example: she still drives, and she is currently working every day at a local school in payroll. She is financially secure. She describes her main hobbies as reading, and socialising with friends. The latter has been particularly affected, and she has struggled to maintain her usual networks. Whilst her weekends are free, she is often too tired from the week go out.

Overall, her health has left increasingly isolated, and simply with time to meet her basic needs, rather than the joyful lifestyle she once had.

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Future planning

Barriers to healthcare:
- Relationship with GP and specialists
- Access:
- Insight
Will
MTDM/MEPOA
ACP/NFR
5 year’s time and comment on if realistic

This section is important, particularly the barriers to healthcare part, which I feel is often missed. It is easy material to talk about whether they have a clear doctor managing their various issues, or a clear doctor coordinating their care, and how they access all this. If they do not, this can easily be a holistic part of your issue list.

Example

Harry has multiple medical specialists managing his various conditions and has good trust in his doctors. However, he does not have a regular GP and there is concern there is not a central doctor coordinating his care.

Worryingly, he does not have an advanced care plan, but his wife is his appointment MEPOA. He has an active will.

In five years, time, Harry sees himself still pottering around in his own words, with the same function he enjoys now. I feel his view of his future trajectory is incongruent of his likely prognosis given multiple advanced cardiorespiratory disease and dependence on others for ADLs. I will discuss this further in my issues list.

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Examination

Mention brief general inspection, and observations
Then introduce most salient findings and relate this back to the patient’s conditions above
Then start with most logical system; you do not need to go into detail on everything if normal and you will have time. It can be reasonable to say, ‘cardiovascular examination was unremarkable’
Present pertinent negatives

Example

On examination, MR XY, is a __ man, initially sitting comfortably in his chair, before moving unassisted to the examination bed. He appeared calm, with no apparent distress or discomfort. He has an IV cannula in his left arm, with no current infusion.
He was normotensive at __, and this was equal in both arms. He had a regular pulse rate of __, was saturating at __% on room air, with a stable respiratory rate of __, and he was afebrile at __
The salient findings of examination were..

Example 2

On examination today, Rachel was sitting comfortably in her chair undergoing haemodialysis. She was engaged, and euthymic.
She was slightly hypotensive at 93mmHg. I could not assess for postural changes. Her other vitals were within normal limits.
In regard to her renal disease, she had a functioning L) brachiocephalic fistula. There was Tenchkoff catheter scar on her abdomen. Her kidneys were not palpable, and there were no renal bruits. She examined euvolaemic. In terms of renal complications, there was no features of anaemia. A parathyroidectomy scar was noted. There was no peripheral neuropathy.
Cardiovascular exam was otherwise unremarkable with a regular pulse, a non-displaced apex beat, and dual heart sounds without no added sounds.
In terms of her obesity, she did not have a Cushinghoid appearance. There was no small muscle wasting. She had full range of motion in her knees without effusions.

Summaries of normal examinations for reference:

Peripheral: On peripheral examination, the hands were warm and well perfused with a capillary refill less than 2 seconds. There were no signs of anaemia, or stigmata of chronic liver disease. Mucous membranes were moist, and JVP was no elevating, lying approximately 2cm above the sternal angle.
Resp: Chest expansion was normal and symmetrical, and trachea was midline. On auscultation, there was bilateral air entry with vesicular breath sounds in all lung zones, which correlated with normal resonance and percussion.
Cardio: On examination of the cardiovascular system, the apex beat was palpable mid clavicular line, 5th intercostal space. Heart sounds were dual with no added sounds or murmurs. There was no peripheral oedema, and pulses were palpable bilaterally.
Neuro: On gross neurological assessment, Mr NP had 6/6 vision, pupils equal and reactive to light, and normal eye movements with no facial droop or hearing abnormality detected. Upper and lower limb neurology exam were normal with respect to tone and power. Reflexes were normal and appropriate. Plantar down going.
Abdomen: His abdomen was soft, non-tender in all zones, with no guarding, signs of peritonism or distension. Murphy’s sign was negative. There was no hepatosplenomegaly or gallbladder detected on palpation and liver span measured approximately 11cm on percussion. There was no lymphadenopathy.

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Summary statement

There is no absolute prescriptive way to do this. Keep it brief
Mention age, and medical/social factors that hasn’t made it onto the issue list that need to be kept in mind

Example:

In summary, Rachel is a 55 lady who faces the chronic burden of end stage kidney disease. Her most promising avenue forward is renal transplantation; however I am deeply concerned that her obesity will limit her eligibility, and lead to further deterioration in her functional capacity, prognosis, and quality of life. It is therefore integral we support Rachel in the endeavour to address this.

In view of this, I have identified the following four issues..

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Issues

There is no prescriptive way to do this. Some key things to keep in mind below are:

Most pertinent issue
Patient’s main concern
Other important/active issues
Psychosocial issue and/or barriers to healthcare

Example

In view of this, I have identified the following four issues..

Addressing her transplant eligibility, with a particular focus on the management of her obesity
Ongoing management of her CKD, including direct and dialysis related complications
Modification of her cardiac risk factors
Establishing and maintaining an adequate support network
Removing barriers to optimal healthcare, with a focus on ensuring appropriate coordination of her health

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Response to questions

It is hard to have a structure for all possible questions, but there can be some general principles. Questions are often about management or diagnostic, and there can be broad structures for these types of questions. There are also some classic questions such as about polypharmacy, financial issues, social issues etc., which I have prepared some general answers and structure for in a separate document.

Management:

Confirm what you were told
1. All physicians go through what is already available when they first meet a new patient, so tell the examiners what information you need to confirm the history you’ve been given.
2. This may lead to you being presented with some relevant information to evaluate that you can them comment on.
Assess the current situation
1. Precipitants
2. TESTS (this is your diagnostic plan…below)
Set treatment goals
1. It doesn’t take much to say and it demonstrates maturity if you can clearly identify what your aims are. This is especially important for “management” problems, in the same way that formulating a differential diagnosis is for “diagnostic” problems (below).
Treatment plan (order can vary depending what’s most urgent)
1. For symptoms
2. For disease
3. For precipitants
Involve the patient and others in your plan
1. Rehab programs
2. Allied health
3. Disease support groups for chronic and/or rare illnesses
4. Family and community supports
Complications of disease and treatment (order may vary)
1. Prevention (e.g., Vitamin D and calcium for patients on steroids)
2. Surveillance (e.g., bone density scanning)
Ensure follow up

Diagnostic

**The following section I have found online; I need to hunt down the original source and credit it**

If it is diagnostic, I would say “My differential diagnosis is...” and then list about 3 in order of your provisional diagnosis first followed by a couple more that are sensible and tailored to your case. Don’t give an exhaustive list of everything it could be – pointless exercise that loses marks and wastes time

Follow this up with, “To investigate this I would...” and see TESTS below. Focus on tests that make the diagnosis (ie, the CT not the FBE)

Then go through your investigations

To diagnose (the most likely cause)
Exclude other causes in differential / Etiology (either or both)
Severity
Treatment baselines
Suspected complications

The key here is to order your investigations in such a way that they follow a logical order and are inclusive (ie- you don’t leave anything out). All tests can be considered in categories and often the same test may be in different or multiple categories depending how you’re using it, eg- a chest xray may be diagnostic of pneumothorax but tell you the severity of cardiac failure (as well as diagnosis). You’ll find there’s a lot of overlap and often the same test crops up in different categories for different reasons for the same diagnosis, that’s OK - at least you haven’t forgotten it. If you run out of time, writing down the mnemonic will at least point you in the right direction without having to be higgledy piggledy and stabbing in the dark. You can also say, “I would order the following diagnostic tests....... To judge the severity I would order....” etc. It sounds more structured. Often a particular category may not be relevant to the problem - just leave it out.