The USMLE Step 1 is becoming more and more clinically oriented. To be honest, I can't really argue with this change. The point of medical school is to produce clinicians, not robots that spit out rate-limiting enzymes (although there are plenty of questions about those too). After sampling a couple question banks this school year, I would estimate that 75% of questions involve a clinical vignette. Before medical school, I am pretty sure I had never even heard the words clinical vignette or pathognomonic so if you are also unfamiliar with the terms, read on! The word "vignette" is of French origin, and literally means "little vine." It was first used to describe the ornate illustrations that began chapters in books. However, in the medical field, a clinical vignette refers to a short report that describes a patient and disease process. Included in the write-up are patient demographics, presenting symptoms, physical exam findings, and laboratory results. The writers of Step 1 also like to include a bunch of information that is useless (so called "distractors").
One of the keys to a great Step 1 score is being able to quickly process a clinical vignette and find the useful information. This takes practice and is one of the reasons that question banks are the most useful test-prep resources out there.
Another key is to remember the various pathognomonic signs for specific illnesses. Pathognomonic is yet another weird word I learned in medical school. It essentially means "a characteristic/diagnostic finding, whose presence indicates a particular disease." They are buzzwords that are instrumental for figuring out what is going on in the patient.
For instance, clinical vignettes will sometimes include details like "machine-like murmur," which should make you leap out of the chair, and yell "patent ductus arteriosus!" Step 1 can be tricky (mean?) and instead of stating the buzzword, they will describe it. Reading about "crystal aggregates of myeloperoxidase" doesn't exactly have the same ring to it as "Auer rods" which would lead you down the acute myeloid leukemia pathway. See how it works?
It is worth mentioning that diagnosing the patient described in the clinical vignette is not always necessary. Sometimes the question will be about an ethical dilemma, a treatment strategy, or even something seemingly unrelated. Reading the question before the clinical vignette can definitely be a useful and time-saving strategy.
I think the best way to understand a clinical vignette is to see one. So I will present my made up patient here, imagine all the juicy questions I could ask about this scenario!
I think the best way to understand a clinical vignette is to see one. So I will present my made up patient here, imagine all of the juicy questions that could be asked about this scenario!
A 58 year-old man with a past medical history of myocardial infarction in 2009, works as a shrimper and comes into your office for evaluation of a skin lesion. He shows you his right hand which has a cluster of three papules on the medial surface and surrounding erythema. He reports the lesions grew over where he was cut by an oyster shell at work. His current medications include metoprolol, and a daily diuretic. He importantly notes a sulfa-drug allergy. Physical exam is notable for a S3 gallop heard best at the left sternal border. Laboratory values are within normal limits.