Test Taking Skills

Clinical Vignette Examples

The following series of clinical vignettes have a question stem that is essentially the same, save for minor differences in demographics. The list of foils is the same for each.

A _____-year-old _____ has had increasing malaise for the past 2 weeks. On physical examination ____ is afebrile and normotensive. There is periorbital edema. A urinalysis shows 4+ proteinuria but no hematuria, glucosuria, or ketonuria. Urine microscopic analysis shows oval fat bodies. The serum cholesterol is 205 mg/dL. A renal biopsy is performed and on light and immunofluorescence microscopy no abnormal findings are noted. On electron microscopy there is effacement of podocyte foot processes. Which of the following is the most likely diagnosis?

A. Diffuse glomerulosclerosis

B. Focal segmental glomerulosclerosis

C. Lupus nephritis

D. Membranous nephropathy

E. Membranoproliferative glomerulonephritis

F. Minimal change disease

A 40-year-old man has had increasing malaise for the past 2 weeks. On physical examination he is afebrile and normotensive. There is periorbital edema. A urinalysis shows 4+ proteinuria but no hematuria, glucosuria, or ketonuria. Urine microscopic analysis shows oval fat bodies. The serum cholesterol is 205 mg/dL. A renal biopsy is performed and on light and immunofluorescence microscopy no abnormal findings are noted. On electron microscopy there is effacement of podocyte foot processes. Which of the following is the most likely diagnosis?

A. Diffuse glomerulosclerosis

B. Focal segmental glomerulosclerosis

C. Lupus nephritis

D. Membranous nephropathy

E. Membranoproliferative glomerulonephritis

F. Minimal change disease

A 15-year-old girl has had increasing malaise for the past 2 weeks. On physical examination she is afebrile and normotensive. There is periorbital edema. A urinalysis shows 4+ proteinuria but no hematuria, glucosuria, or ketonuria. Urine microscopic analysis shows oval fat bodies. The serum cholesterol is 205 mg/dL. A renal biopsy is performed and on light and immunofluorescence microscopy no abnormal findings are noted. On electron microscopy there is effacement of podocyte foot processes. Which of the following is the most likely diagnosis?

A. Diffuse glomerulosclerosis

B. Focal segmental glomerulosclerosis

C. Lupus nephritis

D. Membranous nephropathy

E. Membranoproliferative glomerulonephritis

F. Minimal change disease

A 500-year-old Martian has had increasing malaise for the past 2 weeks. On physical examination the patient is afebrile and normotensive. There is periorbital edema. A urinalysis shows 4+ proteinuria but no hematuria, glucosuria, or ketonuria. Urine microscopic analysis shows oval fat bodies. The serum cholesterol is 205 mg/dL. A renal biopsy is performed and on light and immunofluorescence microscopy no abnormal findings are noted. On electron microscopy there is effacement of podocyte foot processes. Which of the following is the most likely diagnosis?

A. Diffuse glomerulosclerosis

B. Focal segmental glomerulosclerosis

C. Lupus nephritis

D. Membranous nephropathy

E. Membranoproliferative glomerulonephritis

F. Minimal change disease

Did you change your answer?

The key information and the diagnostic finding on electron microscopy is the same for each question. Did you throw that out just on the basis of demographics? The answer is the same for all: foil F, minimal change disease. Yes, it is the most common cause for nephrotic syndrome in children, but it is the third most common cause in adults. The incidence of minimal change disease increases with age in Martians.

We often provide teaching examples for diseases with the most classic findings, including most frequently encountered age, sex, race, and geographic distribution. However, many diseases in real life occur in a variety of settings, and the differences in demographics may not be large. If an objective, diagnostic, confirmatory finding is present then it takes precedence. And for any one patient the disease or condition is either present or not.