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Clinical Vignette Style

A clinical vignette applies to a single patient, and the information given mimics what an expert would extract from a history, physical exam, and ancillary testing. More information may provide multiple ways to answer the question correctly, but may not help students who are used to answering rote memorization type questions with just a single fact or two and who cannot synthesize information easily.

More time is required to read and answer a vignette style question, so adjust the pace of progress through the examination accordingly.

A "two step" or multi-step process makes the question seem more difficult. One may analyze the data and make a diagnosis, but then, rather than just asking for the diagnosis, the question lead-in statement asks for another step. Knowing the diagnosis, what is the pathogenesis, or treatment, or outcome, or additional finding, etc.

Vignette Question Construction

The question stem begins with an introductory statement with demographic information:

"A 22-year-old woman" or "A 3-year-old child" or "A male neonate"

The age and sex are chosen to represent the most common demographics for a disease or condition. For some diseases, such as diabetes mellitus, there is a wide age range and the sex could be either.

For some diseases, a tighter age range is specified. For example, the man presenting with hereditary hemochromatosis will be in his 40's, while the woman with the same disease will present in her 60's. Pyloric stenosis has to occur early in infancy. For monosomy X you must have a female.

The vignette question stem continues with a specific time frame:

"comes to the physician with a 3-day history" or "...with a 10-year history"

This tells you if the problem is acute, subacute, chronic, recurrent, or congenital. This helps tremendously to sort out causation, such as infectious diseases and the possible microbiologic organisms. You can immediately narrow the list of possibilities for many diseases if you know whether the presentation is acute or chronic. People with acute coronary syndromes generally have a history going back hours to days. A patient with osteoarthritis has had symptoms for years. Persons with a congenital coagulopathy may have an acute event, but have a history of such events that goes back years.

The stem continues with the presenting complaint:

"...fever, jaundice, lethargy, hemoptysis, etc."

The clinical presentation may provide you with the classic manifestations of a disease process. The items on the list are there for a reason, either pertinent positives or negatives. There is no extraneous or erroneous data.

The vignette stem continues with physical examination data:

"vital signs, ausculation, palpation, etc."

Only the key abnormal and normal findings will be listed, and they are ALL pertinent. They may be specific or general.

Sometimes the findings are very specific. That patient with the pulsatile abdominal mass is going to have an abdominal aortic aneurysm. The older man with the palpable painful temporal artery is going to have giant cell arteritis. Sometimes the findings are very general. The person with abdominal pain could have any number of possible problems.

The question stem continues with objective data from testing: imaging, laboratory, or other studies.

You may be given visual images. They are always classic examples. First recognize the anatomic site and then the disease process. If it looks like something you've seen before, you probably have, so go with it. This is where understanding the process, rather than memorizing specific pictures helps, because you can generalize.

Small amounts of data may be embedded in sentences in the stem, or large amounts may be presented as a table or in a graph. The data presented are distinctive and represent the classic findings of a disease process or normal body function.

The last part of the stem sets up the problem to be solved with a "lead-in" statement asking the question to be answered:

More generally: "What is the most likely diagnosis?" or "What is the most likely cause?" More specifically: "Which of the following gene mutations is present?"

The first example is the simplest in just asking for the diagnosis, and answering relies more on memorization and recall. The last two examples involve the "two step" process.

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