Tips on how to excel in the long case exams.

Yesterday, yet another group of third year medical students sat for their end of posting exam. This is what we call ‘low stakes’ exam, meaning, even if one does not pass, there are no serious repercussions. Failure usually means one has to either resit a similar exam or repeat the internal medicine rotation/clerkship and then retake the exam. Unlike failing the professional exam which generally means not being able to graduate or move on to the next year.

Still, the general principles of doing well in clinical exams are pretty much the same, regardless of whether it is high or low stakes exam.

1) Time is of the essence.

In OSCE more so than long or short cases, but I have come across candidates who did not have enough time in the long case to examine the patient physically.

This is my advice; in general, a time limit of about 45 minutes to one hour will be given for you to take a history, perform a relevant physical exam, come up with a differential diagnosis and management plan (including investigations and treatment).

If after about 5 minutes into the history, you realise (and you should be able to know by then), that it is going to be a ‘rather complicated’ or ‘not so straightforward’ case, don’t panic. Instead, prioritize.

Make sure you start the physical examination after 20 minutes have passed, regardless of whether you have finished taking the history or not.

That way, you will have at least a good portion of the history done, and a decent (and hopefully relevant) physical examination performed as well, as opposed to having a long-winded history with no physical exam findings to discuss or present.

Aim to finish the physical exam in 20 minutes, whether or not it is complete, leaving you a few minutes (about 5 and 15 if luckier) to organise your notes and thoughts, fill in any missing information, (with practice you should be able to ask questions for the history while examining), re-examine if you need to, come up with diagnosis & management plan and anticipate questions that examiners will ask later (plus formulating the answers in advance).

2) Prioritize.

If the case is ‘complicated’, in that the patient has several medical conditions, multiple previous admissions, diagnosis is unclear in spite of prolonged admission and multitude of tests, then focus on the main problem; that is the presenting complaint or reason for admission. I say ‘or’ on purpose because sometimes, it’s not the same reason, though it often is, and for patients brought in just for the purpose of the exam, their main medical condition.

Let’s give an example.

A patient was admitted with shortness of breath, mild chest pain (score 2/10) and also complained of itch around the abdominal area.

Patient is known CKD stage 5 with DM, hypertension, had previously undergone peritoneal dialysis and is non-complaint with fluid restriction.

While the most likely cause would be fluid overload due to non-compliance to fluid restriction, do not overlook the possibility of an ACS given the patients high CV risk profile. While the itch is very distressing for the patient and can be explained (uraemic pruritus), it is unlikely to be the main reason for admission or influencing the decision to admit, given the whole picture.

Which system to examine?

Best to stick to renal system (in this case, given the working diagnosis), however, you can not not examine the chest given SOB being the main complaint, and you can not not examine the praecordium given the chest pain and SOB, and in general, all patients admitted would have the three main systems (CVS, respiratory and abdomen) examined at least in brief, and so should you, aim to do so in all cases except when clearly confined to one system.

In general, if the main system examined is another, then at least:
– Palpate the apex beat & auscultate the praecordium, (look for JVP if heart failure is a possible differential)
– Percuss and auscultate the lungs posteriorly (where most, if any, signs would be present)
– Palpate the abdomen
If really short of time, then auscultate heart & lungs and palpate abdomen.

Hope this helps.