A classical part of medical education, the long case is simply a discussion of a patient. The student must consult the patient, formulate a differential diagnosis, and decide on appropriate management.
A typical long case is comprised of three parts. The student has 60 minutes for the consultation, 10 minutes to organise his thoughts, and 25 minutes (give or take) to discuss with his examiner.
Opening remarks
I once had a registrar who interrupted every patient presentation with “Stop. Think about it…” before making me restart. The opening remarks are stereotypical of a patient presentation, but one or two sentiences should distil the vital information enough for the listener to understand your assessment.
"I reviewed Mr AB, a 64 year old insulin dependent-diabetic amputee with a background of congestive heart disease and a new diagnosis of end stage kidney disease for which he will require dialysis..."
Medical history
A full medical history should be taken, with care to establish the chronology and progress of the current presenting complaint. Other conditions should be investigated as well, and their management inquired into.
What symptoms led to the diagnosis if there is one, how was it investigated, what risk factors might the patient have, and how has it been managed so far. Is the patient experiencing any complications of the disease or of its treatment.
Medication, supplements, and allergies
Medications should be presented with the history. Realistically, it is difficult to get this out of many patients, and the dosages are but a mystery to most. Nonetheless, this should not be omitted and one might report that they would investigate the dispensed medications or look in the bag of pills the patient brought with them.
Family history
This is vitally important in some contexts and should be included. It would be wise to acknowledge that there is not relevant family history if that is the case, lest the examiner think you have omitted it.
Social history
Enquire into social supports, living arrangements. Assess the patients impression of their own mental state. Things like health literacy can often be understood from the consultation, but formal education and finances ought to be asked about.
Examination
A full examination should be performed and reported, starting with vital signs and then briefly examining the whole body for disease. Only then can one focus on the systems of interest. Some screening examinations might also be in order such as assessing for signs of diabetes or heart failure.
Closing remarks
Having bored the examiner with a detailed description of the history and examination, one should now remind them briefly of the presentation and the background. With the details now explained, one can make a comment on prognosis and considerations for management.
The discussion
The student should formulate and report a list of differential diagnoses and the pertinent positive and negative findings as they relate to each diagnosis. They may be divided into active and inactive problems.
Attention should be paid to existing investigations and the ones that the student would like to order and what they expect to find. Remember that tests should be ordered only if they are likely to alter management.
Management plan
The management plan should be based on all the latest evidence and guidelines which you should have read extensively and understood completely…