Osmosis question writing style guide

This guide is meant to help you write a top-notch medical education question! To get started, please select a topic and write five questions within that topic. When you’re done, compare your questions with our example.

Select a topic that you’re familiar with from the list below. More information on each topic can be found here:

  1. General principles of foundational science
  2. Immune system
  3. Blood and lymphoreticular system
  4. Behavioral health
  5. Nervous system and special senses
  6. Skin and subcutaneous tissue
  7. Musculoskeletal system
  8. Cardiovascular system
  9. Respiratory system
  10. Gastrointestinal system
  11. Renal and urinary system
  12. Pregnancy, childbirth, and the puerperium
  13. Female reproductive system and breast
  14. Male reproductive system
  15. Endocrine system
  16. Multisystem processes and disorders
  17. Biostatistics, epidemiology/population health, and interpretation of medical literature
  18. Social sciences

Identify an important concept and frame up a question that tests application of knowledge, rather than recall of an isolated fact. We want you to focus on writing a great question that tests an important concept. A great question is one that follows the steps below and is in alignment with our question writing checklist. The question should be specific so that it’s possible to arrive at the answer with the options covered. For clinical sciences, use clinical vignettes, and for basic sciences use brief clinical vignettes or laboratory vignettes, as appropriate. Here are some step-by-step instructions:

Step 1. Patient Introduction (for clinical vignettes)

  • Always begin with age and sex, and include only relevant occupational and cultural information (e.g. A 30-year-old man (or woman/boy/girl/infant)). 
  • Use infant for a child <1 year old. 
  • For a pregnant woman, it should look like "A 30-year-old woman, gravida 2, para 1, ..."
  • Never include patient names (e.g. Mr. Smith complains of…).
  • Always include the setting of encounter, reason for visit, and duration and intensity of symptoms (e.g. A 30-year-old man is brought to the emergency department because of severe abdominal cramps for the past six hours.).
  • Always keep the questions and answers in the 3rd person
  • Include only relevant medical history, most recent first; including current medications; family history; social history (e.g. A 30-year-old man is brought to the emergency department because of severe abdominal cramps for the past six hours. Patient’s medical history includes…  Family history is significant for…).
  • Note: In general throughout your writing avoid any contractions (ie: use does not instead of doesn’t).

Step 2. Relevant details of patient visit (for clinical vignettes)

  • Include a general description of the patient (e.g. acutely ill, agitated). 
  • If needed, use the following conventions: __ cm (__ ft __ in) tall and weighs __-kg (__-lb); BMI is __ kg/m2
  • Weight and length for newborns; percentiles for children.
  • Vital signs in the following order: temperature (°C (°F)), pulse (/min), respirations (/min), blood pressure (mm Hg). For example, temperature is 0°C (32°F); pulse is 72/min; respirations are 18/min, and blood pressure is 120/80 mm Hg.
  • If needed, pain scales are written out as follows: “The patient rates the pain as a _ on a 10-point scale.”
  • Physical examination starting from the head and descending to the feet.
  • Include lab values first, followed by noninvasive (e.g., ECG) tests; followed by imaging; and end with diagnostic procedures (e.g., biopsy). Note don’t use the phrase EKG use only ECG.
  • Spell out acronyms where the full term is commonly used (e.g. Use “complete metabolic panel”, not “CMP”)
  • If offering only 2 labs, write them into the body of the question, if offering ≥3 labs, write them in a table like this:

Lab value

Result

White blood cell count

6,500/mm³

Hemoglobin

9.2 grams/dL

Platelet count

410,000/mm³

Note, for any units not mentioned above please refer this document for reference for assistance. If you still cannot figure out what the units you should use are, please contact us.

Step 3. Lead-in

  • Always make sure that the question stem which includes the patient introduction, relevant details, and lead-in, forms an application-type question (e.g. A 62-year-old man develops left-sided limb ataxia, Horner’s syndrome,  nystagmus, and loss of appreciation of facial pain and temperature sensations. Which artery is most likely to be occluded?) vs. a recall question (e.g. What area is supplied with blood by the posterior inferior cerebellar artery?) (50-100 words, not including tables/figures. For questions with no numbers and just words as patient description, can expand to 150 words),
  • Always phrase the lead-in as a question (e.g. Which of the following muscles is most likely to have been injured?).
  • Never phrase the question in the negative (e.g. Which of the following does NOT cause…?).
  • Always use the phrase "Which of the following" followed by "most likely", "most appropriate", "best explains", etc..
  • Never use ambiguous terms like “is associated with”, “is useful for”, “is important”, or vague words like “may”, “could be”, “usually”, or “frequently”.
  • Take a look at these great examples of lead-ins:
  • Which of the following is abnormal? 
  • Option sets could include sites of lesions; list of nerves; list of muscles; list of enzymes; list of hormones; types of cells; list of neurotransmitters; list of toxins, molecules, vessels, spinal segments.
  • Which of the following findings is most likely?
  • Option sets could include list of laboratory results; list of additional physical signs; autopsy results; results of microscopic examination of fluids, muscle or joint tissue; DNA analysis results; serum levels.
  • Which of the following is the most likely cause?
  • Options sets could include list of underlying mechanisms of the disease; medications that might cause side effects; drugs or drug classes; toxic agents; hemodynamic mechanisms, viruses, metabolic defects.
  • Which of the following should be administered?
  • Option sets could include drugs, vitamins, amino acids, enzymes, hormones.
  • Which of the following is defective/deficient/nonfunctioning?
  • Option sets could include list of enzymes, feedback mechanisms, endocrine structures, dietary elements, vitamins.
  • Given the pedigree, what is the likelihood that the next child (specify gender) will have the disease?
  • Option sets could include list of enzymes, feedback mechanisms, endocrine structures, dietary elements, vitamins.

                                              

Step 4. Options

  • Always make options homogenous (e.g. all diagnoses, all next steps in management), plausible, grammatically consistent, numerically consistent, and similar in length. (≤15 words, no more than 1 sentence, and no punctuation at the end).
  • Always make sure that the correct answer would be agreed upon by a group of experts reading the question.
  • Never offer combinations (e.g. “A and B only” or “All of the above”) or an option that is “None of the above”. 
  • When relevant, place answer options in logical order (e.g. 5mg, 10mg, 15mg, 20mg).
  • Alphabetize options and capitalize only the first letter of the first word and proper names.

Step 5. Correct and incorrect answer explanations

  • Always offer a short explanation for each wrong answer using relevant information from the question stem (20-50 words).
  • For the correct answer always write the following statement: “Correct: See Main Explanation below.”
  • Please use present tense and active voice when describing any medical phenomenon.
  • Always include a main explanation of the correct answer that includes a careful analysis of the question, and does not simply restate messages found in common review books. The key is to pull out tricky concepts and explain them in clear and interesting ways (100-200 words).
  • Include relevant additional information such as references and links to short YouTube videos (<4 minutes).

Step 6. Major takeaway

  • Always include a short explanation that summarizes the explanation for the wrong answer (20-50 words).
  • Always bold the key term or concept that the question is about, and have that be the first part of the explanation. 

Step 7. Images

  • Include relevant images in the question stem, answer options, and in the main explanation.
  • Only use images from Wikipedia
  • Always include a link to the image that is being used.
  • Always confirm that the image being used is licensed under CC-BY or CC-BY-SA. See Creative Commons website for more information.

A 4-year-old boy is brought to the emergency department because he has a sudden onset of abdominal pain and vomiting. On physical exam, he appears uncomfortable and has a mass in the right lower quadrant of his abdomen and hyperactive bowel sounds. A CT with contrast is obtained and is shown below with a red arrow on the key finding. Which of the following is the most likely diagnosis?

(https://en.wikipedia.org/wiki/Intussusception_(medical_disorder)#/media/File:Invagination_001_CT_cor.png)

  1. Appendicitis

Incorrect: Appendicitis can cause sudden onset of nausea and severe right lower 

quadrant pain, however, bowel sounds are typically hypoactive or absent. In addition, typical findings of appendicitis are a non-filling appendix with distension and thickened walls of the appendix and the cecum, none of which are seen here.

  1. Intussusception

Correct: See Main Explanation below.

  1. Meckel diverticulum

Incorrect: Most patients with Meckel diverticulum present without symptoms and are 

identified incidentally through imaging. Among symptomatic pediatric patients, the most presentation is painless rectal bleeding with occasional complications (e.g. obstruction). 

  1. Necrotizing enterocolitis

Incorrect: Necrotizing enterocolitis is typically seen among among premature, 

formula-fed infants. A CT that shows Pneumatosis intestinalis, free air in the bowel 

wall, is pathognomonic for this condition. 

  1. Strangulated hernia

Incorrect: Strangulated hernia is a surgical emergency that occurs when a loop of bowel 

gets trapped outside of the abdominal cavity and has its blood supply cut off. Typically, there is severe pain, erythema, tenderness, and induration over the herniation site. 

Main explanation:

Intussusception is a medical condition in which a part of the small intestine invaginates or folds into another section of intestine, like a collapsible telescope that is sliding closed. Intussusception causes bowel obstruction and also increases pressure on the bowel walls which can cut off the arterial blood supply to the affected intestinal area. Prolonged intussusception can lead to a tear in the bowel wall (perforation), infection of the blood stream or peritoneal cavity, and death of bowel tissue. This case describes the classic presentation of intussusception and the arrowhead on the CT scan shows the lead point, which is where the initial part of the small intestine is invaginating into itself. Intussusception typically occurs in infancy through young childhood, and physical exam may reveal a "sausage-shaped" mass, felt upon palpating the abdomen. Some children present with bloody stools. While the bloody stools have classically been said to resemble “red currant jelly”, one study found that in reality, only a minority of children with intussusception had stools that could be described as "red currant jelly.” Therefore, intussusception should be considered in the differential diagnosis of all children passing bloody stools.

Major takeaway:
Intussusception in infants and young children often presents as an abdominal mass that causes obstruction, and can be seen on imaging as a telescoping of the small intestine. 

 

(https://upload.wikimedia.org/wikipedia/commons/thumb/9/9e/Intussusception_EN.svg/2000px-Intussusception_EN.svg.png)

Link to Video: https://www.youtube.com/watch?v=B9C5BHTX-dA

References:

  • Cera, SM (2008). "Intestinal Intussusception". Clin Colon Rectal Surg 21 (2): 106–13.
  • Yamamoto, LG; Morita, SY; Boychuk, RB; Inaba, AS; Rosen, LM; Yee, LL; Young, LL (May 1997). "Stool appearance in intussusception: assessing the value of the term "currant jelly."". The American journal of emergency medicine 15 (3): 293–8.
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