Long Case and Short Case

One main difference between the American and British medical education system is the use of long case and short cases in the exam. I still remember my final medical exam, the long and short cases that is. I wouldn't recall much about the written examinations, except that there were essays, with some options, and MCQ's.

For most medical students, preparing for written exams should not be a great hurdle because majority would have developed a way of preparing for such. A huge part of preparing for MCQ type of exam is to practice doing questions. For the majority of people, the challenge is time. So during practice it would be smart to time oneself. Regular practice is needed and the momentum should increase nearing the exam, so that the candidate can 'peak' their performance during exam time. (Somewhat similar to training for a half marathon).

So if the NBME is two months away, and there are about 1400 questions in the question bank, average questions to be done daily is 1400/60 = 23.3 questions per day, do or die. If it is a real pain, in the first 2-3 days start with 5 questions per day then slowly build up momentum to achieve 25 questions per day and maintain this till the last week prior to exam, where you can up to 30 questions/day.

For essay type of questions, what we used to do was look at all the past year questions available, to have an idea of the type of questions and what had been asked in the past. Sometimes, there is a pattern, allowing some kind of 'prediction' and sometimes there isn't. That is irrelevant. Looking at the past year questions will allow one to focus on areas that could potentially come out in future exams. Never do anything blindly. Never study without first understanding how you will be assessed.

My general advice to medical students on how to operate on a daily basis is:
1) Spend time on the wards seeing patients, clerking patients, examining patients, don't read your books on the wards. You need to read but spend your time on the wards wisely. You can read later at home.
2) On the wards; work in pairs or groups of three, with colleagues whom you respect and are of relatively equal standing. Take turns to take history, do the physical exam, and present to each other. Practice, practice, practice. Then ask questions pretending to be the examiner. When you get a chance to present to a doctor, use it. It is a golden opportunity for feedback and how you can improve. Some students have the ability to speak fluently without preparation, you have an advantage, but talking nonsense fluently will not get you the marks you need. If you are the introverted type like me, you will need more practice on the presentation part, so present to your dog, cat, fridge, mirror, friend, anyone willing or otherwise to listen.
3) When you get home after the day is done with ward work and teaching, it would be best to sleep first (after meals, praying, shower etc) before studying. Some people love to study at night, others during the early morning hours. Find what works best for you. The main message is don't study when you're tired. You will not be very productive. Rest first and then study. The hours spent studying too should increase as you near the exam. What to study? Apart from doing exam questions, I also read around the cases I have seen during the daytime at the ward, plus the themes in the exam questions. Time is a limitation for most people, so I would discourage just reading text or textbooks for the sake of completion. Targeted learning and meaningful learning will allow the type of learning that relies lest on memorization and would last longer.

During the weekends, there are additional hours where one can spend doing other things like socialising, shopping for groceries, household chores, recreation, exercise and unwind. But do maintain the momentum of practising exam questions and studying. You can even make up for days lost during the week.

The long case

There are in general different understand and interpretation of what a long case is. The British system, which is what Malaysians follow, would usually involve a carefully selected patient who has a suitable history and some positive physical examination findings, often one who is not acutely ill, but rather with chronic, stable signs, and is able to give the history him/herself. Sometimes, especially when there are many students taking the exam at the same time, there may be a shortage of these 'ideal long case' type of patients, and less then ideal cases may be used. Less then ideal may mean that the patient is unable to give a detailed history, or there is a lack of history, or the presentation may be atypical for the particular condition, or the patient has no clear diagnosis after a barrage of tests which all comeback negative....so yes, there is an element of luck and the solution to reducing this 'unfairness' is the OSCE exam, where each candidate will be examined on the same patient, using several patients in many different stations.

The long case is easier than the short case because you will be given about 45 minutes to take a history and do a relevant physical examination without the presence of any observer, usually behind closed curtains. The unofficial advice to the student is, at the very beginning, to get the patient 'on their side' by explaining the importance of the exam to the student, that the exam does not in any way impact patient management, and to please do not contradict what the student says in front of the examiners later. In other words, build rapport. It is also useful to ask the diagnosis first, and work backwards, though this may not always work if the patient is unaware or unable to communicate.

The candidate is usually given empty pieces of paper and maybe a board to write on. It is a good idea to jot down the headings for example presenting complaint, history of presenting illness etc at the very beginning so that you do not miss anything, and leave large amount of spaces so you can add in information should you forget something and later remember during the process. You must also watch the time very closely and aim to finish the history and physical 10 minutes earlier so that you can arrange your notes, come up with a differential, and anticipate questions regarding management before the examiner walks in.

The examiners (usually there's two but there might be there is an observer wants to join in) would ask if you are ready at around 45 minutes - 1 hour. The earlier candidates may have less time than later candidates during the day, as the exam continues, this is just the normal process. After presenting, the history, physical examination findings, differential and management, the examiners will usually ask you to demonstrate any of the physical examination findings and then discuss management. They may give feedback regarding your performance or they may choose not to. At undergraduate level, the examiners usually give leading questions if one is straying away from the correct path/answer. The examiners will usually have a detailed note of the patients history and physical examination findings, plus the diagnosis, and they may have a checklist to ease the assessment process.

The Short Cases

The short cases are a bit more tricky and the purpose of it is to assess your interaction with the patient, but more importantly, your skill at performing the physical examination and ability to discern between what is normal and what isn't. One average, a student may see three or four cases for the internal medicine part of the exam. Most of the time, as many as 10 or more patients will be placed in an area (maybe one ward prepared just for the exam) behind separate curtains or in separate rooms. You are not allowed to ask any questions other than "may I examine your......?" or " do you have any pain anywhere in your tummy?" before you start palpation.

You are expected to use your powers of observation to pick up things that will aid in the diagnosis, without obtaining the history, or using entirely the physical examination, to work out a diagnosis or differential, and then discuss the pathophysiology, possible etiology or management.

You must follow exactly the instructions given, which will be very specific for example, examine the respiratory system, look at the hands, look at the face, examine the praecordium, look at the fundus etc.

You may clarify if you are not sure what to examine, again, the examiner would lead the student if they are at lost or diverge from the correct answer.

It is best to give a running commentary while examining, and present as you find, although this may backfire if your findings are later found to be conflicting.

It is very impressive to examine efficiently, present the findings with the likely diagnosis or differential and then include a management plan. As long as your answer is correct. Usually, if the examiner doesn't interject, that means you are on the right path.

Do not spend minutes doing a part of the exam that could be done a few seconds. This can be very irritating to watch. Do not hesitate moving from one part of the exam to the next. Do not mumble when presenting your findings. Be confident, and this naturally comes with practice. Be confident, even if you are wrong, at least you sound good.

Make sure you know how to work the beds and how other apparatus works, this 'shows' that you have spent adequate time on the wards and can only be learned through experience.

Examples of Long Cases

I was the last candidate that day for the medicine long cases. In Trinity College Dublin, my alma mater, the long case for medicine is combined with psychiatry. So a student has a one in five chance to get a psychiatry for the long case. While I enjoyed psychiatry as a medical student, I cringed at the thought of getting one for the finals. Luckily, I did not get such a case.

Instead, the patient was a very pleasant, youngish middle aged lady who was newly diagnosed with leukemia. I cant remember which one. There wasn't much to report in the history. She had felt unwell and went to her GP. The GP did some routine blood tests and picked up the cancer. She did have hepatosplenomegaly. As I had explained earlier, had there been other more suitable patients on the ward, this patient would probably be a more suitable candidate for the short cases.

By the time the examiners came, they seemed rather tired and sort off 'fazed out' during the presentation. Thankfully, it was brief. The focus of the history though, was on the social part because anyone with newly diagnosed cancer will have a lot of issues to look at, can the patient continue working, how would they manage with chemotherapy, is there someone at home who can help take care of them when they are ill, etc. So if you don't have a lot of stuff to report, make sure you do a detailed social history (also if the case warrants it, for example a patient who is blind but has ischaemic heart disease, or a patient with diabetes who needs insulin but is unable to inject themselves due to rheumatoid arthritis).

I was asked to demonstrate my findings (hepatosplenomegaly) and then discuss the general principles behind the management of leukemias (and the different types), but not in great detail as specialists are not allowed to examine their own area of expertise, for example a gastroenterologist must not be an examiner for a case of crohns disease and a chest physician should not be the examiner for a COPD patient.

My husband got a patient with a stroke, another excellent case for the medical finals. The were only pure motor findings so the working diagnosis was lacunar infarct. The patient had difficulty hearing so my husband had to practically shout throughout the history and physical examination.

Other long cases for medicine include heart failure, multiple sclerosis, COPD complicated by cor pulmonale, lung cancer, cirrhosis....

One student recollected getting a patient for the long case who was unable to give any history at all due to a mixture of dementia and probably dysphasia. The student proceeded to do a mini mental state examination and a physical exam. During the presentation, the student emphasised the need to look for old medical notes and to obtain a collateral history. He passed.

It's funny that I can't seem to recall my surgical long case. My husband got a patient with Crohns disease with multiple surgical interventions, who was not aware if the diagnosis.

For paediatrics, I was introduced to a 10-12 year old boy who I was told should be able to give the history by himself. They were right. I was disappointed that the parents were not there, but that disappointment went away within the first few minutes when I realised that the patient was a 'professional' patient. It was pretty obvious this was not the first time he was included in the medical exams. He had stage 4 clubbing due cystic fibrosis. Admitted with pneumonia. All paediatric long cases must have their height and weight plotted on the centiles. Failure to thrive is as important a sign to pick as unintentional weight loss is in adults.

In the obstetric and gynaecology finals, each student will either get an obs or a gynae patient for the long case. There were no short cases, instead they had a viva, which is a live voice exam with two examiners immediately after the long case. If the long case was obs, mine was a lady post lower segment caesarean section, she was lovely but I cant recall any other detail about the case, then the oral exam would focus on gynae. I remember being asked about vaginal prolapse and chlamydia infection. It still amazes me that I can recall the event to that amount of detail more than a decade later. Talk about the effect of stress and memory formation.

Examples of Short Cases

If there is a patient with a murmur, no doubt they will be invited to participate in the exam. Make sure you are comfortable examining the praecordium and anterior chest of female patients. I find a lot of students dwindle at this, even the ladies. After examining and presenting the findings, you will be asked what type of lesion you think it is, and what the possible causes are. Instead of giving lists, it is more impressive if you can taylor it to the particular patient you just saw. "Given the young age of this patient, the most likely cause of the x murmur is infective endocarditis" is better than saying "The causes of x murmur include bla bla bla...". You may be asked about management.

Other favourite short cases include pleural effusion. Stony dull to percussion. What are the causes? Make sure you answer by dividing into exudates and transudates.

Rheumatoid arthritis hands. "Examine this patients hands".

Lymphadenopathy for example in the cervical area. What is the differential diagnosis?

Ptosis, bilateral in a patient with myasthenia gravis. Instruction was 'examine this patients eyes'.

For the surgical finals I remember seeing a lady with a new mastectomy scar. I was asked to describe what I saw, give the diagnosis and then was asked what I wanted to do next. I replied I would like to examine the remaining breast and the axillae.

I was taken to see a patient with a urostomy bag. I was asked where suitable sites for stoma bags would be (away from the umbilicus, bony prominence etc, apparently this is a favourite question), and whether the piece of gut used was retro or antero-peristalsis.

In the paediatrics short case I had a toddler who was screaming from beginning to the end of the brief exam. I believe the baby was upset even beforehand so it was not me that made the baby cry, but uncomfortable for me to continue with all the racket. I did ask the examiners whether I should continue and they said yes. The child had bilateral stumps at the ulnar side of the MCP joint, due to surgically removed 6th digits. I was asked what I would like to examine next, I replied the feet. I was asked "what one question would you ask the mother?"

For internal medicine, Baliga 100 Cases remains a favourite book and Stryders Short Cases for the MRCP will give examples that is meant for postgraduate exam but can be applied at the undergraduate level too.

Hope this helps.