Long case synthesis and presentation

• The format should roughly follow the standard order of presentation but don’t be restricted on this. Sometimes you need to flexibly alter it to tie the information together.
• Be as succinct as possible. Your job is to somehow condense a complex and often long-winded and vague story into an interesting and meaningful narrative.
• Make the presentation flow. Use prose. Don’t stop and start with headings. Instead use an introductory phrase, ‘He gives a history of….’, ‘A review of system also elicited a a few other undefined issues….’, ‘Examination revealed…’
• Don’t give the spiel in monotone with no breaks and punctuation. Preface each new section with a brief pause and then a change in tone of voice.
• You aren’t finished until you have summarised the main findings, given a differential, an investigative strategy and a management plan
• Don’t be frustrated or intimidated by unexpected events. Experienced senior clinicians know that the clinical assessment does not always go to plan even with the best of intentions.
• Assume that you are the primary physician involved with this patient for the rest of their life. Anticipate all the issues that may arise (short, mid and long term), when you would refer, what you would tell them.
• Find a balance between reporting the patient’s story verbatim and providing an appropriate medical commentary e.g. "the patient described a feeling of ‘dizziness’ which further questioning sounded like vertiginous symptoms", "he mentioned he was a small blue pill for an irregular heart beta which I take to be possibly digoxin".
• If there are parts of the story which are vague, unsubstantiated or unknown then say what you would do to fill in the gaps. "The patient could not give me a reliable list of his medications and I would need to speak to his carer or GP to confirm this.", "He was unable to recall the result of his endoscopy and I would like to obtain a copy of the report", "I would need to confirm the active ingredient in durogesic patches"

What is the examiner looking for

• Are you able to carefully gather facts 
• Can you combine the facts into a meaningful problem list
• Can you determine an investigative strategy, patient review program to diagnose or define the extent of the problems
• Can you take in account all the problems to tailor a personalised management plan

Other tips about the history

• If a diagnosis, test or treatment has been recently been performed this is rightly presented in the history not at the end. e.g.'two months ago he presented with similar symptoms and had a exercise stress test that was negative and further investigation with coronary angiogram was not pursued. The cardiologist did not commence anti-angina therapy but did address a few lifestyle factors and commenced him on lipid-lowering agents.
• Your own personalised formulation of the case should happen at the end. You may make brief comments of your interpretation of findings during the presentation but save a more comprehensive summary at the end.

Opening up proceedings

• Plan to give a confident punchy little summary at the beginning. The examiner is always going to open up with something like, ‘So tell me about Mr. Smith….’, ‘how did things go’, ‘now what did you find….’. Don’t be caught flat-footed. A bright 30 second opening will give you a bit of confidence, put the examiner at ease and improve the flow and context of the rest of your presentation e.g. Begin with ‘Yes, I was asked to Mr. Smith who initially presented with increasing abdominal distension in the setting of chronic alcohol abuse’. ‘It appears that he is somewhat of a diagnostic and/or management problem’.
• If you feel that you already are confident of the likely diagnosis then say it now.
• If you aren’t sure preface the presentation by saying he has a ‘perplexing', ‘unusual’ or ‘atypical history’ of chest tightness and a chronic dry cough' and continuing ‘His story began 2 weeks ago when….’
• Preface the opening with a comment of any factors that may have affected the assessment e.g. Non-English speaking background, dysphasia, patient upset, patient had a seizure, drowsiness, vague or inconsistent historian.

PMH or HPC first – not really a dilemma at all

• Often the HPC is tied up with the PMHx e.g. SOB/asthma, chest pain/IHD, visual disturbance/MS e.g. Mrs Walcott presented with 4 days of worsening joint pain in the setting of long standing remitting rheumatoid arthritis. Mr Flint awoke with an episode chest pain with a known history of both ischaemic heart disease, reflux oesophagitis and recurrent pulmonary emboli. Mrs Doe was referred by her GP with severe anaemia on a background of chronic renal failure and previous bleeding peptic ulcers. Mr. Jackson was being investigated for recurrent DVT.
• Mention only the parts of the PMHx which are relevant at the time. Place non-related PMHX later in the presentation
• The same is for the Review of Systems – mention all relevant symptoms in the body of the presentation. Incidental symptoms can be provided just prior to the examination findings. Any new information found in the ROS should be elaborated on in the same way as any other primary complaint e.g. heartburn – intermittent lasts few minutes, several times a week, worse with spicy food or laying flat, relieved with Mylanta.

Undefined problems

• Indicate that some parts of the medical history may be incomplete or not fully defined. They have been only partially evaluated in the past. Some are based on weak evidence or only the patient’s interpretation of events.
• Mention the current information to date and those yet obtained e.g. chronic diarrhoea – negative screen for coeliac, colonoscopy performed but results are pending
• Even if a diagnosis has not been firmly established comment on how the symptoms affects the patient functionally (see below)

Defined problems

• Ensure that all problems are described in terms of cause and severity. Not ‘history of angina’ but ‘infrequent angina and requiring GTN sublingual only with heavy exertion.' Not ‘previously suffered anaemia’ but 'had a period of anaemia complicating severe gastritis but now well controlled with PPI’.

Functional history

• Always incorporate comments about the impact of symptoms or illness on the patient’s function i.e. mobility, showering, dressing, feeding self, administering medications, cooking, cleaning etc – for instance debilitating heart failure requiring home oxygen and has difficulty leaving the house, debilitating Parkinson’s disease and cannot mobilise without wheelchair.

Social history

• Consider two factors. What is it about the patient’s circumstances which make managing their medical problem difficult? How will this patient’s illness impact those around them including their dependents?
• Consider social issues – unstable accommodation, living alone, unemployment, multiple dependents (including pets), social isolation, rural settings, no family support, debilitating chronic illness (physical or mental).
• Utilise community resources – community nursing (RFDS. H@H services), mental health, domiciliary support, community groups (e.g. muscular dystrophy association), local councils (e.g. transport, shopping), social work services

Summarising the case

• After presenting the history next present the examination system most relevant to the case eg. knee pain> MSS/rheum/ortho exam, vertigo > neuro exam, dyspnea > cardio-respiratory exam. Follow with the rest of the exam in the typical order – CVS, Resp, GIT, Neuro, Endo/Haem, MSS.
• After presenting the history and exam summarise the key points – the major symptoms, the chronology (abrupt/gradual, persistent/intermittent, worsening/fluctuating/remitting), the severity (mild/debilitating), any prior treatment (monotherapy / multiple medications) including treatment response.

Tying the information together – experts need only apply

• It is not enough to make a diagnosis and generate a differential diagnosis
• You need to tie in all the bio-psycho and social factors that will ultimately dictate the management
• Does the treatment of one condition affect the control of another e.g. steroids for COAD and Type II DM, beta blocker for AF control and history of asthma.
• Do psychosocial factors influence where and how you would treat this patient e.g. elderly, socially isolated, mental illness, indigenous, recent migrant

Generating a problem list

• Order the problem list from active to inactive, acute to chronic

Ordering the summary

• Outline all the problems. In the list mention the problem, its severity and its cause if known eg. #1 unrelieved chest pain possibly cardiac in origin requiring investigation, #2 significant social issues that will need addressing #3 mild well controlled asthma #4 poorly managed diabetes with early evidence of end-organ damage.
• Next, expand on the problem list and indicate your investigations strategy and follow-up plan
• Investigative strategy – don’t just list a battery tests.  Indicate what specific test you wish to perform, what you are looking for, how you would proceed based on the result you get e.g. 'I would proceed to CTPA if the d-dimer was negative' NOT 'I would consider performing a d-dimer, V/Q scan and CTPA.'
• Last mention how you would educate the patient who you would get involved e.g. asthma plan, demonstration of Epi-pen, diabetic educator, disability help groups etc