What Vignette?

In order to qualify for a residency position a medical student has to complete multiple tests successfully. The most important of these is the USMLE. These tests are divided into three segments, called steps. Step one tests basic scientific knowledge in topics such as biochemistry and microbiology. Steps two and three are more interesting in that they test an applicant’s ability to form a diagnosis derived from a simplified clinical vignette.

I often think back to these vignettes. They inspire a sense of achievement and history. I’ve come a long way since the boards and now face vignettes that are slightly more challenging. They even talk back.

For example I remember this one from my second step:

"53 year old alcoholic male comes to the emergency room complaining of a sharp epigastric pain radiating to his back, accompanied by nausea and vomiting. His breath smells of alcohol, what is the most likely diagnosis"?

Any medical student worth his salt shaker would easily recognize this obvious case of pancreatitis.

Three years have passed. Now more experienced, my clinical vignettes have become slightly more challenging. Daily, my patients introduce me to more mysteries in the form of complaints. I must say, the mysteries have gotten more interesting and, sometimes, more practical.

I will challenge you with yesterdays' patient in the form of a clinical vignette, I’ll even provide a multiple choice, just like the boards:

"62 year old male with past medical history of congestive heart failure, hypertension, hypercholesterolemia, diabetes, asthma, and a past stroke. The patient recently was admitted to the hospital with severe pulmonary edema, barely able to breath. He underwent cardiac cath that showed an indication for bypass surgery but then signed out against medical advice. He absolutely refuses to take medications. Occasionally, he likes to use cocaine and heroin. Today his chief complaint is “I don't feel so well”. What is the most likely diagnosis"?

a- No Shit!
b- You Don’t Say
c- Take Some Responsibility for yourself you out of control, self destructive, ##$^% idiot
d- I Don’t Care