Test Taking Skills

Clinical Vignette Examples

The following series of clinical vignettes have question stems that seem similar, but there are key data that help sort out the correct, and different, answer for each. The demographics have been deleted to illustrate the problem-solving process with less distraction. ALL vignette questions will have demographics, because that is the standard style (all individual patients have age, sex, and race), but that information may or may not be of importance. Race is not often given in question stems, because human disease is not restricted to a given race. Genetic factors can play a role in increased prevalence for disease some population subgroups, but still disease is not exclusive to a given subgroup.

A _____-year-old ______ has experienced swallowing difficulty for the past 2 months. The patient has lost 3 kg during that time. On physical examination there are no abnormal findings. Upper GI endoscopy is performed and there is an ulcerated _____ lesion of the lower esophagus. A biopsy is taken and the microscopic appearance is shown in the figure. Which of the following is the most likely risk factor for development of this patient's disease?

A. Alcohol abuse

B. Diabetes mellitus

C. Gastroesophageal reflux disease

D. Helicobacter pylori infection

E. HIV infection

F. Scleroderma

If the accompanying image shows adenocarcinoma, and knowing that the esophagus is involved, then regardless of any other information, the strongest relationship is to GERD. The foil of alcohol abuse makes this question harder for students who cannot separate risk factors for squamous cell and adenocarcinoma. The additional clue of lower esophagus gives another way to answer the question.

A _____-year-old ______ has experienced swallowing difficulty for the past 2 months. The patient has lost 3 kg during that time. On physical examination there are telangiectasias of the skin. His blood pressure is 160/110 mm Hg. Upper GI endoscopy is performed and there is an area of stricture involving the lower esophagus. A biopsy is taken and the microscopic appearance is shown in the figure. Laboratory findings show serum creatinine of 3 mg/dL and glucose 70 mg/dL. Which of the following is the most likely risk factor for development of this patient's disease?

A. Alcohol abuse

B. Diabetes mellitus

C. Gastroesophageal reflux disease

D. Helicobacter pylori infection

E. HIV infection

F. Scleroderma

If the accompanying image shows extensive fibrosis, then scleroderma becomes the best answer, particularly in view of the hypertension, probably renal disease with elevated serum creatinine, and telangietasias, which are also features of this systemic autoimmune disease. Simple GERD cannot explain the other findings, though it could explain stricture alone. Hence, you must use all of the data in this question stem. Look for an integrative disease process to account for all findings.

A _____-year-old ______ has experienced swallowing difficulty with pain for the past week. The patient has lost 3 kg during that time. On physical examination there are no abnormal findings. Upper GI endoscopy is performed and there are 3 sharply demarcated ulcers of the ______-esophagus from 0.3 to 0.9 cm in diameter. A biopsy is taken and the microscopic appearance is shown in the figure. Which of the following is the most likely risk factor for development of this patient's disease?

A. Alcohol abuse

B. Diabetes mellitus

C. Gastroesophageal reflux disease

D. Helicobacter pylori infection

E. HIV infection

F. Scleroderma

If the accompanying image shows multinucleated cells and intranuclear inclusions, then a viral process is present and herpetic esophagitis the likely diagnosis. The "two-step" process here is recognition that this is an opportunistic infection with immunodeficiency, and thus the answer is HIV infection. The clue of the "punched out" ulcerations along with pain of inflammation of more acute onset is characteristic for herpes simplex virus infection, without looking at the image. It is often the case that a question with an image can be answered without the image.