“A 72 year old woman is brought to the emergency room…… has not been able to eat and drink in 2 days…..serum glucose 72mg/dl…..urine ketones…..right hip fracture….answer is Hormone sensitive lipase, next.”

When reading a clinical vignette, we are taught to always read the last line or two first – it’s usually the most important part. This is probably some of the best advice I got for solving U- World questions. The vignettes are long, and you usually have to just skim most of it and keep your eyes sharp for the 1-3 words or phrases that are key to the answer.

My 79-year-old grandfather called me a few weeks ago and told me it doesn’t hurt when I pee but sometimes it looks like there may be some blood. But don’t worry it doesn’t hurt and it’s probably just another kidney stone or something.

Translation: A 79-year-old man presents with a 3-month history of painless hematuria with a remote history of kidney stones. My mind jumps to page 629 in First Aid: bladder cancer. I’m taking my NBME for Renal/ Hem/ GI this week, I know this information. I don’t say anything – I tell him to go see a doctor, and he makes an appointment.

“A 72-year-old woman is brought to the emergency room after lying on the floor for the past two days.”

My grandfather sees the doctor who refers him for scans. Turns out there is a bladder mass, and they need to biopsy but it’s definitely cancer. They will remove it and it will be ok.

“The patient’s neighbor called the police after phone calls were not answered and no one opened the door”

My grandfather undergoes a procedure to remove the cancer and the biopsies are sent to pathology to figure out the diagnosis and to see if the cancer has spread. They remove a large mass.

“She is found awake on the bathroom floor lying in feces and urine.”

The pathology report comes back:

Histology – urothelial carcinoma with squamous differentiation…. high grade…..invades lamina propria….invades muscularis propria. Diagnosis is transitional cell carcinoma grade 3. Part of me pleasantly surprised how the words are no longer foreign but I’m shocked because I wasn’t wrong, but this isn’t another U-World question. I can’t skim this one because its real. But aren’t they all real?

“The patient says she fell and injured her right hip and was unable to get up to call for help. She did not drink or eat anything in that time.”

This poor woman – imaginary yet no less real than my grandfather – fell and fractured her hip and was lying alone on her cold kitchen floor for 2 whole days because no one was there to help.

I’ve gone back to that question a lot lately – not to the final line, but to the deeply human, desperate, and lonely vignette that I have been taught to skim over. This is something that happened to someone; all these cases are real, and they happen to real people. We all know it, but for now we need to skim and focus on the answer. The actual story isn’t the “high yield” part in medical school – we focus on the educational objective listed below the practice question:

“Educational objective – Hormone sensitive lipase is found in adipose tissue, where it functions to drive the breakdown of stored triglycerides into free fatty acids and glycerol. During times of starvation, this enzyme provides substrates for hepatize gluconeogenesis and ketone body formation.”

My grandfather is the strongest person I know, and he’s optimistic so we will be optimistic with him. The doctors have taken their NBMEs and STEP exams and are trained to know what to do. I will get there at some point too and so will the rest of my class. These are our future patients.

We are learning to understand disease through these questions, but we must also learn to understand the people in them. Until then, I have some U-World questions to do.

– In honor of my Opa, who I love very much.