Table Of ContentMastering the
medical long case
A tribute to my parents and my family
And to Hanna, with love
Mastering the
medical long case
An introduction to case-based
and problem-based learning
in internal medicine
S Rohan Jayasinghe
MBBS (Honours Class 1) (Sydney), MSpM (UNSW), PhD (UNSW), FRACP
Director of Cardiac Services and Cardiology, Gold Coast Hospital
Professor of Cardiology, Griffith University School of Medicine
Professor and Chair of Medicine, Bond University School of Medicine
Queensland, Australia
Sydney Edinburgh London New York Philadelphia St Louis Toronto
Churchill Livingstone
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Previously published by MacLennan & Petty, 1999
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National Library of Australia Cataloguing-in-Publication Data
_______________________________________________________
Jayasinghe, S. Rohan.
Mastering the medical long case : an introduction to case
based and problem based learning in internal medicine /
S. Rohan Jayasinghe.
2nd ed.
ISBN: 978 0 7295 3839 8 (pbk.)
Includes index.
Bibliography.
Medical history taking.
Diagnosis--Case studies.
Medicine--Examinations, questions, etc.
616.0751
_______________________________________________________
Publishing Editor: Sophie Kaliniecki
Developmental Editor: Sunalie Silva
Publishing Services Manager: Helena Klijn
Editorial Coordinator: Lauren Allsop
Edited by Kay Waters
Proofread by Pam Dunne
Cover and internal design by Trina Mcdonald
Typeset by TnQ Books and Journals Pvt. Ltd.
Contents
Author’s note vii
Preface viii
Reviewers xii
Acknowledgments xiii
Part 1 Clinical assessments
1 Approach to the long case 3
2 Approach to various common symptoms 16
3 Cardiology 23
4 Respiratory medicine 51
5 Neurology 68
6 Nephrology 85
7 Oncology 96
8 Haematology 109
9 Endocrinology 130
10 Infectious diseases 147
11 Alcohol and hepatology 163
12 Gastroenterology 173
13 Rheumatology 186
Part 2 Clinical investigations and interpretations
14 Clinical investigations and interpretations 209
Part 3 Long case discussions
15 Long case 1. T hemes: haematological malignancy,
complications of chemotherapy 255
16 Long case 2. Themes: thrombocytopenia, acute myocardial
infarction 261
17 Long case 3. Themes: ischaemic heart disease, diabetes,
airways disease, chronic diarrhoea 267
v
CONTENTS
18 Long case 4. Theme: renal transplant 275
19 Long case 5. Themes: diabetes, obesity, obstructive
sleep apnoea 282
20 Long case 6. T hemes: chronic liver disease, chronic
alcoholism, gastrointestinal bleeding, hepatitis C 290
21 Long case 7. Themes: rheumatoid arthritis, osteoporosis,
chronic airways disease 297
22 Long case 8. Themes: HIV, immune deficiency,
haemochromatosis 304
Appendix A: Discharge planning and community care 312
Appendix B: Internet directory of internal medicine 313
Index 315
vi
Author’s note
This book is meant to be an examination aid and not a therapeutic manual. Clinical
medicine as described here is what is practised in most leading teaching hospitals and
tertiary referral centreesss iiinnn AAAuuussstttrrraaallliiiaaa,,, aaannnddd rrreeelllaaattteeesss tttooo ttthhheee eeexxxpppeeerrriiieeennnccceee ooofff ttthhheee aaauuuttthhhooorrr aaannnddd
colleagues. The author disclaims any legal responsibility associated with the application
of the modalities of clinical management discussed here. Medicine is changing ffaasstt...
Although every attempt has been made to provide accurate and complete information
consistent with the practice of medicine at the time of publication, information given
here may become outdated due to changes in medical science. Readers are advised to
refer to therapeutic and clinical manuals for the practical application of the concepts
discussed in this book. This book is an examination aid only.
vii
Preface
Primum non nocere.
[First do no harm. First principle of medicine.]
It is a great privilege to be invited to write this second edition of Mastering the medical
long case. This endeavour has enabled this popular textbook to be made more compre-
hensive and current. The management principles discussed here are in keeping with
the latest evidence and trends in modern medicine.
The fundamentals in the introduction I wrote for the first edition still hold true, no
matter what developments have taken place in the science and technology of medical
practice. The basics of clinical evaluation, beginning with the building of confidence
and rapport, followed by thorough history taking and physical examination, cannot
be replaced or bypassed. Mastering the medical long case is all about perfecting the
practice of good and safe medicine. With the advancement of modern therapeutics,
a demographic shift is taking place in the patient population. Patients are surviving
longer and as a consequence tend to accumulate more diseases along the way. Their
lists of medications keep getting longer and they have social, economic and occu-
pational problems that also need addressing. This complexity in the management
of patients is fast becoming the norm in clinical medicine, and it is not surprising
that many authorities consider the long case the most significant component of their
respective examinations. The clinical examinations of the Royal Australasian College of
Physicians, undergraduate and postgraduate medical schools and postgraduate training
authorities worldwide, have the long case examination or an equivalent in their
assessment programs. Particularly with the Royal College of Physicians in Australia,
the long case has become a significant parameter by which a physician’s competence is
measured at the qualifying examination.
With advances in global communication and the rapidity and ease of global
travel, developments in medicine seem to spread to all corners of the earth very
quickly. Accordingly, medical practice has become more or less uniform all over
the world.
During a discussion on the best way to prepare for the long case section of the
physician’s examination, a reputed specialist at the Prince of Wales Hospital in Sydney
(where I trained as a registrar) said that it is all about ‘just becoming really good at
what you usually do in the wards with managing your patients’. This statement sums
viii
PREFACE
up the basic principle behind the required preparation for the medical long case.
A very good physician trainee or a medical student needs to be able to assess patients
with multiple serious medical problems thoroughly and systematically, analyse the
issues involved, identify the problems in their order of priority (both medical and
social), organise relevant investigations and formulate a comprehensive management
plan. The candidate should do this with every patient they encounter in their daily
clinical practice. So carrying out these daily tasks with diligence and curiosity may be
all that is necessary to achieve long case mastery. A mere reproduction of this is all that
is necessary at the examination to pass with flying colours!
PRACTICAL TIPS
Discuss your patients with your seniors and ask questions when you have any doubts.
Do not be a passive participant. Always try to imagine what you would do if you were
in charge. Take responsibility in the crucial decisions regarding the management of
your patients. Look up the latest journals and publications to keep in touch with the
most recent trends in diagnostics and therapeutics, and try to apply these in the care
of your patients. Ask what your consultant thinks about the plan of management you
propose.
It is important to have worked with many different specialists in order to be
experienced and comfortable with the management of patients with various disorders
involving different organ systems. Specialties such as renal medicine and cardiology
give the candidate or student exposure to the management of quite ill patients with
many complicated medical and social problems. Oncology gives an opportunity to
participate in making crucial decisions regarding active treatment and best palliation.
All specialties have made tremendous progress in therapeutics in recent years, and the
only way to learn the application of such modern therapeutics in the management of
patients is to work with the relevant teams.
As you can appreciate, the long case is essentially a process of gathering all the
relevant information from the patient and bringing this together to understand
what is happening with the patient at that precise moment. Once that objective has
been achieved, the next step is to decide what needs to be done to tackle the various
problems that have been identified. Decision-making is the key to the long case, and
the candidate’s decisions (preferably judicious, mature and confident) can make the
difference between passing or failing the exam.
Be organised
Although it is important to have a commanding knowledge of the various major
medical conditions, this in itself is insufficient to be able to handle a long case
confidently and competently. As the long case is an interplay between many serious
and minor medical conditions, the candidate has to be able to apply his or her
knowledge appropriately to understand how the combination of various diseases is
affecting the patient. Direct application of the recommended therapy for a condition
may not be feasible in the long case setting, due to the presence of complicating
factors of other diseases and the potential for adverse reactions with multiple other
medications. In addition, there may be psychological, social, financial and cultural
issues that further complicate the case. For example, a patient who has ischaemic
heart disease as well as asthma may not tolerate beta-blocker therapy well, while a
patient who has ischaemic heart disease as well as migraine will not tolerate nitrate
ix
