Tiredness... but happy ;p

had a wonderful weekend of relaxation and fun!!! went to beaufort with a group of uni ppl, trekked around a bit on mt cole, and had some nice food... were there to also see the hospital (beaufort still has a nice hospital with comprehensive range of ancillary services in addition to general practice, despite being such a small town) and talk with some of the staff there, to get a feel for what rural practice involves and so on... ;p

was a great escape tho!!! on the back of a busy psych rotation, it's nice jus to have a change of scenery and not have to worry about anxiety, depression, substance abuse, psychosis, eating disorders and suicidality for a change... especially good was to finally have some quality time with sally and jus enjoy each other's company for a while, to know and appreciate in each other the qualities God has blessed us with, without so many other things on our minds... we have too few moments like this... 's the problem when we're both jus such busy ppl!!! (yes, med can be mad...) still hanging in mood for a break now, not particularly itching to return to study!!!

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to now respond to request for the recipe for long-case success:

despite popular advice, long-cases aren't what you do from day to day in the ward with patients once you start working... in the real world, rapport and friendliness are paramount, to gain the trust of the patient, to ensure that your alliance is one forged on honesty and genuine care, and to bring about some simple therapeutic effect thru the wonderful healing power of human interaction...

long-cases, on the other hand, are meant to be a systematic, short-lived chance for you, as medical student, to demonstrate to examiners that you can obtain and organise information from a patient about him or herself to conform to a structure, such that others in the profession can rapidly understand and anticipate your thinking and clinical judgement... there is far less importance placed on rapport and friendliness - instead clinical precision is what's required...

so what's the recipe?!? - you could get any patient at all, so don't start off with the patient in your head... you'll put this together in a structured fashion as you do your history and examination... you start off with a bony structure that goes something like:

-opening statement - name, age, ethnicity, occupation (or social support modality), lives where, with whom, presenting with (insert brief one-phrase summary of history of presenting complaint) on a background of (insert most salient features of background history)...
-history of presenting illness - chronology is important and probably the best way to organise this info... pick an important event (or when the patient was last well) in the recent past and go thru the steps of detailing the key symptoms and outlining relevant symptom groups... detail is very important here - don't spend forever on it, but this is one area where you cannot afford to cut content... make sure also to put some detail in here abt possible precipitants...
-relevant history - recent, longstanding, or pertinent episodes, conditions or operations... make sure to talk about indications, course of illness, treatment (especially recent changes in medications) and prognosis of all relevant conditions... - the key word here is "relevant"... you should highlight relevant conditions first before going onto the next section...
-past history - all the rest of the medical/surgical history that's not relevant to the case at hand... this is more-or-less a list, and little detail is required...
-medications - i like to put medications here, but this may go immediately after history of presenting complaint if, for example, the recent illness has been triggered by a change in medication, or a side effect of medication... alternatively, medications may hold little relevance, in which case a passing comment is sufficient (e.g. this patient is not currently on any medications)... in any case though, especially at this stage, no medication should ever be dismissed as trivial, and all details should be obtained as much as possible (i.e. what medication, how much, when to take, how long they've been on, indication, side effects, and patient's adherence to prescription)... don't forget over-the-counter medications...
-smoking/drugs/alcohol - i put these all together... like medications, if particularly relevant, this can be put immediately after the history of presenting complaint... remember that detail is important, and examiners usually don't like the use of the term "social drinker", or "occasional user"... if possible, give an idea of how often and how much... and if dependency is a possibility, go through symptoms of dependency, pattern of use (morning drinking, for example), how central patient's life is around the drug, withdrawal symptoms, past overdoses, attempts at quitting, thoughts about quitting... if illicit drugs, be wary and suspicious and make the connection with crime, especially for the more lucrative ones such as cocaine and heroin... forensic history can follow this too, if relevant...
-family history - this is cursory... don't get confused and start talking about the complex developments in the patient's family life... family history simply means genogram of immediate family (i.e. family structure), causes of death if any, family function (do they live together, or parents divorced, for example) and presence or absence of any particularly relevant medical conditions or operations within the immediate and extended family...
-social history - talk about educational, occupational, social development and current status here... tailor detail level depending again on how relevant you judge the information to be... most importantly, since social history often encapsulates the essence of the person's day-to-day routines, this is where one of the most important issues of illness and its impact may be highlighted... i'm referring, of course, to functional impairment... it's difficult to overstress how important and useful an outline of functional impairment can be, especially within the context of a patient's life and the things the patient regards as important to him or her...
-developmental history - can be relevant also, particularly in psych patients... talk about pregnancy, birth, early years (milestones), separation anxiety, primary and secondary academic, sporting achievements, and socialisation at school... family environment at home (high expressed emotion, for example, can play a part in the incidence of relapse of psychosis) or any particularly relevant losses during the patient's childhood should be commented on...
-systems review - optional, but often encouraged to be put in here... most frequently, it's jus a heading to show that you've done systematic questioning about other health issues... almost always, you'll say "systems review was unremarkable" (because if you picked up anything relevant, you'll have put it earlier in your history)
-risk - keep this in mind when you're interviewing, especially if patient is depressed or has chronic pain or chronic illness... risk is about risk to self, to others, of absconding, and of non-adherence to treatment... insight into the patient's condition may be of particular note...

okay, you now have a backbone... this is to be stored in the head, and if possible, written down on a proforma just moments before you see the patient... in the interview, ensure that the patient is comfortable at the start, because you'll be putting a lot of pressure on him/her with all your questioning!!!

how to question in a long-case is very different from seeing patients as a continuing care doctor... it's more like seeing them at a once-off visit, where you need to make a diagnosis quickly and arrange a bare-bones treatment plan you know will work, and you never see the patient again... what i'm saying is that a big emphasis on rapport and empathy is not going to help!!! (of course, be sensitive, but let them know that you're going to ask a lot of questions in a short amount of time - and just do that)... - you want to keep in charge of the interview, no matter what...

i'd suggest starting by asking lots of closed questions to fill in the opening statement (what's your name, how old are you, are you living at home, who's at home with you, are you currently working etc), patients expect you to ask these anyway...

from there on, direct the interview to the current situation with a question like, "what problem has brought you to hospital?" or "what has been happening in your life recently?" - then, keep focusing on the current issue... if the patient starts straying, don't let them stray too much into the past, unless they're clearly feeding you very relevant information (like the course of their ulcerative colitis for a patient who's presented for rectal bleeding, for example)... if the patient says anything very striking, e.g. they mention pain, then jump on it and keep asking specific details about that symptom until you've fully characterised it... when the patient has given you a good picture abt the presenting illness, then review with specific questioning any relevant symptoms they haven't described (so, if they've talked a lot about the headache, then ask about any loss of consciousness, faintness, weakness, numbness/tingling, visual problems, hearing problems, photophobia, neck stiffness etc)...

steer the interview then to focus on medications, or past medical history (whichever you feel is more likely to be relevant to the case based on what you know so far), and explore each of those areas in detail... remember to separate medications into "now", "used in past", "recently changed"... and remember to ask about adherence to medications... remember to separate past medical history into relevant and less-relevant... and present the relevant ones in detail, but the less-relevant bits as no more than a list...

continue in this fashion, asking lots of specific questions and keeping the patient on track, sticking to the skeleton outlined earlier...

make a point of considering the other important issues throughout as being functional impairment and risk (see later)...

when it comes to physical examination, remember that the most important step is inspection!!! the reasons why - you should give the examiners a very good idea of what the patient looked like (describe both general appearance and behaviour, in addition to any signs you looked for specifically)... so, something like "Kim was a young-looking woman of Chinese ethnicity, lying on the bed wearing a hospital gown with 2 pillows and the head of the bed raised to 45 degrees... she looked uncomfortable and appeared cyanotic, with bluish lips, and was wheezing... she had two ventolin inhalers lying on her bedside table..."

then, given limited time only in the exam, you should go straight for the examinations that you anticipate you'd have findings... quick hand-inspection is always worthwhile... as are all vital signs (get temperature from chart if you don't have a thermometer)... oximetry and blood glucose are also extremely valuable in most settings...

risk assessment - a section you're only formally taught about in psychiatry, but is quite important for all long-cases really... risk assessment should elaborate in features of the history if they are already prominent there, but needs to be stated here separately, because it is so important... risk assessment consists of four main elements (for inpatients) - risk of self-harm, risk of harm to others, risk of absconding, risk of non-adherence... these four aspects have to be detailed in terms of current and past relevant thoughts and behaviours (e.g. high level of suicidal ideation currently, but no previous attempts)... if there is a positive past history of suicide attempts, then detail the method, intent and setting...

formulation/summary - don't simply repeat your opening statement, but recap it... this is where you start to present interpretation... up until now, you have done absolutely no interpretation, not made any diagnoses or anything, except that you would have done well to have presented it in a manner that shows that you understand the patient and their illness (show this by the way you group symptoms and examination findings, and the relevant negatives you talk about - also, don't neglect the all-important symptom of functional impairment)...

structure of formulation - you should talk about predisposing, precipitating, perpetuating and protective factors, in that order... make these quick, with maximum of 2 sentences for each category (preferably one sentence for each)...

diagnoses are last... followed by management... remember that principles are most important, so rather than diagnosing asthma immediately (unless it's obvious), then you should say something like "my differentials include all causes of acute respiratory distress, in this case, most likely asthma, but could also be bronchiolitis or pneumonia..."

better go now... may write more later... but have tute!!! ;p get lots of practice, and happy long-casing!!!

God bless,
dave