How to write long case in final year mbbs

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long case MBBS final year format history examination diagnosis management viva tips

Here is a complete guide to writing a long case in final year MBBS:

How to Write a Long Case - Final Year MBBS

What is a Long Case?

A long case is a structured clinical examination where you are given 30-45 minutes alone with a patient to take a full history and examine them, then present your findings, diagnosis, and management plan to examiners for a 15-20 minute viva. It tests your clinical reasoning, not just knowledge.

The Format (Write in This Order)

1. Biodata / Introductory Statement

Start with a one-liner summary:

"Mr. X, a 45-year-old male farmer, non-smoker, presented with progressively worsening breathlessness for 3 months."

Include: Name/initials, age, sex, occupation, address, informant (patient or relative), and reliability of history.

2. Chief Complaints

List complaints in chronological order with duration:

Breathlessness - 3 months
Cough with expectoration - 2 months
Pedal edema - 1 month

Use the patient's own words. Do not write a diagnosis here.

3. History of Present Illness (HOPI)

This is the most important section. For each complaint:

Onset - sudden or gradual?
Duration
Character/Quality - nature of the symptom
Site and Radiation (for pain - use SOCRATES mnemonic)
Severity - how much does it affect daily life?
Timing - continuous or episodic? Morning or night?
Aggravating and relieving factors
Associated symptoms - relevant positives AND negatives
Progress - improving, worsening, or static?
Treatment received so far

Pertinent negatives matter: "No fever, no hemoptysis, no weight loss" - these help narrow your differential.

4. Past History

Similar episodes in the past
Previous hospital admissions or surgeries
Known medical conditions (DM, HTN, TB, asthma, epilepsy, etc.)
Relevant illnesses in childhood

5. Drug History

Current medications with dose and duration
Previous medications
Allergies - always ask and document

6. Personal History

Diet (vegetarian/mixed)
Appetite and weight changes
Bowel and bladder habits
Sleep pattern
Menstrual history (in females - LMP, cycle regularity)
Marital status

7. Family History

Similar illness in family members
Hereditary conditions
Draw a simple family tree if relevant (e.g., for genetic conditions)

8. Socioeconomic History

Occupation and occupational exposure (dust, chemicals, fumes)
Living conditions (crowded housing - relevant for TB)
Socioeconomic status
Smoking (pack-year history), alcohol, substance use
Travel history if relevant

9. General Physical Examination (GPE)

Write findings systematically:

Built and nourishment: Well built / moderately nourished
Consciousness: Alert and oriented to time, place, person
Vital signs: Pulse (rate, rhythm, volume, character), BP (both arms), temperature, respiratory rate, SpO2
Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy, Edema (PICCLE - remember this)
Jugular venous pressure (JVP)
Look for: tongue, teeth, thyroid, skin changes, hands (clubbing, koilonychia, leukonychia, palmar erythema), eyes (jaundice, anemia, Kayser-Fleischer rings)

10. Systemic Examination

Examine the most relevant system first, then cover all others briefly.

For each system:

Inspection - describe what you see
Palpation - what you feel
Percussion - note
Auscultation - findings

Systems to cover:

Cardiovascular system (CVS)
Respiratory system (RS)
Per abdomen (PA)
Central nervous system (CNS)
Musculoskeletal (if relevant)

Always document a brief normal finding for systems not primarily involved.

11. Summary

Write a 4-6 line summary pulling together the key positives and negatives:

"Mr. X, 45/M, non-smoker, presented with 3 months of exertional dyspnea, 2 months of productive cough, and 1 month of pedal edema. On examination, he was tachypneic, had bilateral pitting pedal edema up to knee, raised JVP, and on chest auscultation had bilateral basal crepitations. CVS showed displaced apex beat with a pansystolic murmur at the apex."

12. Provisional Diagnosis

State your most likely diagnosis with reasoning:

"Provisional diagnosis: Congestive cardiac failure secondary to dilated cardiomyopathy"

Then list 2-3 differential diagnoses.

13. Investigations

List investigations in logical order:

Routine: CBC, LFT, RFT, urine R/M, blood sugar
Specific to the case: ECG, Echo, CXR, ABG, sputum AFB, etc.
Special: CT scan, biopsy, endoscopy as needed

For each investigation in the exam, note the expected findings.

14. Management Plan

Structure this as:

Non-pharmacological: Diet, activity restriction, physiotherapy, smoking cessation, education
Pharmacological: Drug class → specific drugs (mention dose if you know), duration
Surgical/Procedural if applicable
Monitoring and follow-up
Complications to watch for

Tips for the Viva After Presentation

Start confidently - give your one-line introduction without hesitation
Speak slowly and clearly - examiners are assessing reasoning, not speed
Justify your diagnosis - "I think this is X because of A, B, and C findings"
Know your common cases cold: CCF, COPD, CRF, cirrhosis, DM with complications, stroke, TB, DKA, SLE
If you don't know something, say "I am not sure, but I would consult guidelines / my senior" rather than guessing
Never change your diagnosis mid-viva unless you genuinely realize an error - stand by your reasoning
For investigations, always explain why you are ordering each one

Common Mistakes to Avoid

Writing the diagnosis in the chief complaints section
Listing symptoms without duration
Forgetting pertinent negatives in HOPI
Skipping systems not directly involved
Vague summaries - be specific with findings
Management plan with no drug names - at least mention drug classes

SOCRATES Mnemonic (for any pain complaint)

Letter	Meaning
S	Site
O	Onset
C	Character
R	Radiation
A	Alleviating factors
T	Timing
E	Exacerbating factors
S	Severity (0-10 scale)

PICCLE Mnemonic (GPE findings)

Pallor - Icterus - Cyanosis - Clubbing - Lymphadenopathy - Edema

Good luck with your finals. The long case rewards methodical thinking over cramming - a well-structured presentation with sound reasoning will score well even if your diagnosis is not perfect.

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