Preparing for the FCICM Hot Case can feel like stepping onto a stage. It is considered the hardest and most stressful part of the exam.

You’re on the spot, watched closely, and every move matters. The first few minutes — from when you’re handed the stem outside the door to the “dance” of orienting yourself at the bedside — are crucial. Get this right, and the rest of the case flows. Get it wrong, and you’re scrambling to catch up.

This article focuses on that opening act.

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📝 The FCICM Hot Case Stem

Every word in the stem has a purpose. Use it.

Outside the Door – The Two Minutes of Gold

When the examiner gives you the stem, you don’t have much time — just two golden minutes. (Time starts when you receive the stem paper in your hand)

The goal is not to conjure up every possible diagnosis but to create a mental framework:

• Decode the stem: note the patient’s NAME, age, diagnosis, key interventions, and trajectory (improving, deteriorating, post-op, etc.).
• Identify the question behind the stem: is this about ventilation, sepsis, cardiogenic shock, neuro, or something else?
• Ensure your plan of attack answers the question: Pertinent systems, in which order to acquire all the information required to answer the question
• Pick up all clues from outside: Wash hands sign (? C.difficile enterocolitis), Double strength Norad sticker, Delirium poster, Airborne or ERP precaution

Ask yourself: “What are they really asking me to show them?”

Two minutes can feel like forever if you’re calm and structured — or like two seconds if you panic.

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⎆ Entering the Room – First Impressions

When you step in, you’re setting the tone. Walk in calm, confident, and deliberate. Don’t rush.

The first 30 seconds to 1.5 minutes matter. Before touching the patient:

• Introduce yourself. You are a consultant.
• Scan the room.
• Infusions: what’s running, what’s supporting the patient?
• Monitors: don’t just glance at numbers — look at the trends, alarms, and waveforms.
• Ventilator: mode, settings, FiO₂, pressures.
• Environment: is there a dialysis machine, ECMO circuit, intra-aortic balloon pump?

This is the non-verbal part of the FCICM hot case: the examiner is watching whether you see what an intensivist should see.

You could do this either as an end-of-bedogram (if the room is complex with multiple machines) or proceed with…

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💃 The Dance Around the Bed

Now begins the “dance” — a structured, flowing sweep around the bedside that gives you a 360° view.

A simple clockwise approach works well:

1. Relevant Infusions: Why Milrinone? or Defibrotide?
2. Lines, tubes, drains: identify them and infer why they’re there.
3. Equipment: ventilator, dialysis, pumps.
4. Bedside clues: relatives, documentation, emergency equipment.
5. The patient: posture, sedation, respiratory effort, haemodynamic support.

Always ask for ‘TUBS’: Temp – Urine & Bowel outputs – Secretions

Don’t rush to lay hands immediately. Narrate your thinking as you move:

“This patient has high-dose noradrenaline with ventilatory support with high FiO₂ — I’m expecting severe septic shock physiology.”

Verbalising shows the examiner your thought process and reassures them you’re systematic.

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🔥 Common Pitfalls

Tunnel vision – diving straight into monitors or lines without seeing the patient.

Forgetting the framework – losing sight of what the stem asked you.

No structure – appearing flustered or random in your approach.

Missing the obvious – not noticing that the patient is peri-arrest before you even start examining.

Looking but not internalizing – going through the motions without actually registering the context or meaning of what you are observing.

Sloppy examination – Rushing and disorganized without calculated and refined steps

Poor time management – which will lead to a sloppy examination. The dance should be a maximum of 1.5 minutes.

History taking – don’t do this! It’s a clinical examination exam.

Forgetting the patient’s name – Tip: Use their name as soon as you enter the room.

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Conclusion & What’s Next

The opening act of the hot case is all about setting yourself up. Those first few minutes are not about showing off knowledge — they’re about demonstrating calm, structure, and situational awareness.

Get the outside-the-door thinking and the dance right, and you’ll own the rest of the FCICM hot case.

👉 In Part 2: The Examination and Presentation, we’ll dive into how to structure the physical exam and present findings to the examiners with authority.

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✅ Hot Case Part 1 Checklist

• Use the Talley O’Connor Examination book to practise finessing Neurology, Cardiology, Respiratory, and GIT examinations
• Decode the stem quickly
• Build a mental framework
• Stay calm and deliberate
• Scan the room before the patient
• Structured “dance” around the bed
• Think out loud for the examiner
• Practise with your stethoscope – each unit’s may differ and is of inferior quality

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💡 Remember: the examiners are not trying to trick you. They’re asking, “Would I trust this doctor with my ICU?” These first minutes are your chance to show them the answer is yes.

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💎 Bonus

Common approaches to practise:

• COPD patient
• Post-cardiac surgical patient
• Post-cardiac arrest survivor
• The patient with an intra-abdominal catastrophe
• The patient who has an abdominal aortic aneurysm
• The patient who has had a SAH
• The patient with a head injury
• The patient with a spinal injury
• The patient with burns
• The transplant patient
• The obstetric patient
• Long stay ICU patient

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💎 Key Videos

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If you need additional resources to help you prepare, you can check out my Ultimate Resources page or try Learning about Stoicism with my book recommendation, and let it help you overcome mental barriers to push through this temporary hurdle.

You got this!