 I'm going to start with the content because you're probably watching this video because you've got a test coming up and you don't have a lot of time. So here we go. My strategy for handling long vignette type questions on exams. Step one, read the last two sentences first. Step two, look at the answer choices. And step three, quickly skim over the rest of the information in the vignette. That's it. Go try it out. You can thank me later. Okay, let me explain just a little bit more. You want to start out by reading the last two sentences of a question because a lot of the time that's all you need to answer the question. How many of you have spent valuable time pouring over all the details of a question? Lab values, imaging, physical exam, history, only to get to the last sentence and realize you didn't need any of that to answer the question? I have and it sucks. So now I always start by reading the last two sentences of a question. But why the last two sentences and not just the last sentence? I'll tell you why. Because a lot of the time I've actually found that the second to last sentence gives you a critical detail and that the last sentence actually asks you the question. So a lot of the times you need the last two sentences. So I guess another strategy is just reading the question backwards until you feel like you have enough information to answer the question. But that's just not very systematic and therefore it's not efficient. And I prefer to follow a simple formula for every single question so there's no guesswork, there's no uncertainty and you just go right through and answer everything the same way. So therefore I always start by reading the last two sentences, then the answer choices and then the rest of the question. So let's look at an example that illustrates how this works. Okay, so here's the example. 16 year old boy presents with right upper quadrant pain that started two hours ago. Symptoms started with mild generalized abdominal pain and anorexia before localizing to the right side of his abdomen. His temperature is 99.5, his blood pressure is 116 over 76, respirations are 18 and saturation is 99% on room air. And physical exam reveals mild tenderness to deep palpation of the right lower quadrant. Which sign would indicate retrocecal location of the appendix? A, Murphy's sign, B, obtrader's sign, C, psoas sign or D, rosving sign. So as you can see, the last sentence gives you everything you need to answer the question. The rest of the vignette is totally unnecessary and is honestly just there to kind of waste your time and maybe even confuse you, either way, it's not necessary. Now you can pick out this type of question by looking at the language they use in the last sentence. It's very objective and not subjective. It's asking about a disease or a medication or whatever, but it's not asking about a specific patient. Notice they're saying which sign would indicate retrocecal location of the appendix. They're not saying what is the most appropriate diagnosis or the most appropriate treatment or imaging for this patient. They're not saying what would you order next or what would you do next for this patient or anything like that. It's very objective language. So this is a simple general question to determine the location of the appendix before doing any imaging. You either know it or you don't. No more details in the vignette can possibly help you. And in fact, they might even confuse you and they'll definitely waste your time. So read the last two sentences in a question first. Then read the answer choices and then read the rest of the question if you feel like you need to. Let's do another one. 74-year-old woman presents to the ER complaining of abdominal pain, constipation, and fecal seepage for four days. She's been taking hydrocodone as needed for pain associated with a rib fracture two weeks ago. Her heart rate is 80, respirations are 16, blood pressure is 134 over 86, temperature is 97.6, her abdomen is diffusely tender to palpation and distended. There is no guarding or rebound tenderness. She has a dilated rectal vault with hard stool and fecal occult blood test is negative. What is the most likely diagnosis? A, colon cancer, B, diverticulitis, C, fecal impaction, D, sigmoid volvulus. All right. Did you notice the subjective language in the last sentence? This question is asking about a specific patient, not a disease process or a medication. It's asking about this specific patient that they're talking about, which tells you that you'll probably need some more details from the rest of the vignette as opposed to the last question, but we don't want to do that first. We still want to read the last two sentences, then the answer choices, and then the rest of the question. Let's do this process and look at the question again. So we read the last two sentences and the answer choices and we see that this patient has a dilated rectal vault with hard stool and her fecal occult blood test is negative. To me, this eliminates choices A and B right off the bat. Of course, you might find some details in the rest of the vignette that might put those choices back on the table, but at this point, it's just not likely. When they're painting a picture of colon cancer or diverticulitis, usually the occult blood test will be positive. So right away, I'm already suspecting that it's going to be C or D. And then reading the last sentence, the actual question, it's asking which one is the most likely. Now I ask you, what's more common, fecal impaction or volvulus? Of course, it's fecal impaction. Now, don't get confused, sigmoid volvulus is the most common type of volvulus in elderly patients, but that's not what the question is asking. The question is asking which of these is the most likely diagnosis and fecal impaction is more common than volvulus, much more common. So therefore the answer would be fecal impaction. So if I was in a hurry, I would honestly feel comfortable picking C after just reading the last two sentences and the answer choices without even looking at the rest of the details in the vignette. But since we're not in a hurry, why don't we skim the vignette and see if we could pick out any buzzwords or any more information that'll help us support our diagnosis or maybe support one of the other ones more. Okay, fecal seepage, that really supports fecal impaction. It could indicate that the patient has some other type of mass effect, so it could support cancer, but we already don't suspect cancer because of the negative occult blood test, which they gave us in the second to last sentence. So now I'm even more sure that it's fecal impaction. She's a febrile, so diverticulitis is now less likely, and the rest of these wouldn't have a fever. And she's complaining of constipation and the digital rectal exam reveals hard stool, which is just more evidence for fecal impaction. Okay, so they gave you like five things to support the diagnosis. I picked out just by reading the last two sentences and the answer choices. They don't always give you this much detail, and sometimes the details they do give you will actually make you more confused instead of more certain, like in this case. But either way, I just wanted to illustrate why it's important to start by reading the last two sentences and then the answer choices before you read anything else. I also wanted to illustrate the thought process that you should have. It's exactly like they teach us in school with forming a differential diagnosis. You listen to the chief complaint and then you use the history, the physical, the labs and the imaging studies to move things up and down on your differential diagnosis and see which one you think is most likely. Except here on the exam, you already have a differential diagnosis, so all you have to do is eliminate things based on the information that you're given. So if you start reading the question from beginning to end, the differential diagnosis floating around in your head is huge. But if you start by reading the last two sentences, you know what question you're being asked. You probably have a very important detail or two to work with and help you narrow down your differential diagnosis. And then by reading the answer choices, you actually have your differential diagnosis, which is probably much shorter than what you have floating around in your head. And that just saves you time and energy. Another thing I wanted to discuss really quick is buzzwords. If you do have to read the rest of the vignette to help you answer the question, you shouldn't be reading every single word very intently. You should be skimming for buzzwords that stick out. So for example, in this question, the second sentence actually gives you two huge buzzwords, hard stool and negative occult blood. Then the rest of the vignette gave us a bunch more. Constipation, fecal seepage. She's a febrile. There's no guarding or rebound. And with every detail I read, the more certain I am that the patient is constipated and experiencing stool impaction. Remember, if it looks like a duck, it waddles like a duck, and it quacks like a duck, it's probably a duck. Don't second guess yourself and think about the very rare instances where an elephant might waddle like a duck or a tiger might quack like a duck. It's a duck. Stop overthinking. They're not trying to trick you. Just go with your gut and move on. So I actually wrote down a bunch of other examples to go through with you, but I know you're in a hurry, so I just wanted to give you the content, give you the information and send you on your way. So good luck on your exam, and I'll see you in the next video.