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SIXTH EDITION
CASE FILES®
Internal Medicine
Eugene C. Toy, MD Gabriel M. Aisenberg, MD
Assistant Dean for Educational Programs Associate Professor of Medicine
Director of Doctoring Courses Department of General Internal Medicine
Professor and Vice Chair of Medical Education McGovern Medical School at The University
Department of Obstetrics and Gynecology of Texas
McGovern Medical School at The University Health Science Center at Houston (UTHealth)
of Texas Houston, Texas
Health Science Center at Houston (UTHealth)
Houston, Texas
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
00_Toy-IM_FM_p000i-xxvi.indd 1 04/09/20 3:26 PM

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DEDICATION
To the McGovern Medical School class of 2020,

who have continued to challenge and inspire me to be the
very best teacher possible. You are the first class of our new curriculum,
and you trusted that the theoretical dreams
and abstract fancies weaving the basic and clinical sciences with the art
of medicine in the Doctoring Courses would work. Four years later,
we know it worked, primarily because each of you believed
and worked diligently to fill in the gaps that we missed.
You are each what is most special about medicine and are the reason I teach.
May you have a wonderfully fulfilling and
rewarding career, and continue to learn and heal.
—ECT
To my beloved wife, Cynthia, and my children, Lucas, Tomas, and
Carola, whose support, love, and understanding fill me
with hope, with energy, and with passion. To Dr. Herbert L. Fred,
a mentor and a friend. He may not be around,
but his light will shine forever.
—GA

This page intentionally left blank

CONTENTS
Contributors / vii
Preface / xvii
Acknowledgments / xix
Introduction / xxi
Listing of Cases / xxiii
Section I
How to Approach Clinical Problems....................................................................1
Part 1. Approach to the Patient.................................................................................................. 3
Part 2. Approach to Clinical Problem-Solving.....................................................................10
Part 3. Approach to Reading.....................................................................................................13
Section II
Clinical Cases.......................................................................................................19
Wellness (Cases 1-2).................................................................................................................21
Cardiovascular (Cases 3-13)..................................................................................................39
Pulmonary (Cases 14-19).................................................................................................... 153
Gastrointestinal (Cases 20-23).......................................................................................... 213
Hepatic, Gallbladder, Biliary (Cases 24-27)................................................................... 255
Renal, Genitourinary (Cases 28-30)................................................................................. 295
Musculoskeletal (Cases 31-35).......................................................................................... 323
Neurological (Cases 36-39)................................................................................................. 377
Critical Care (Cases 40-41).................................................................................................. 415
Immunological, Infectious (Cases 42-46)...................................................................... 435
Endocrine/Hormonal (Cases 47-53)................................................................................ 487
Hematological (Cases 54-58)............................................................................................. 557
Alcohol Abuse/ Toxicology (Case 59-60)....................................................................... 605
Section III
Review Questions....................................................................................................................... 627
Index / 641


CONTRIBUTORS
Radhini Abeysekera, MS4

Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Meningitis, Bacterial
Vascular Catheter Infection in a Patient With Neutropenic Fever
Heba Ahmad, MS3
Medical Student
Houston, Texas
Anaphylaxis/Drug Reactions
Urinary Tract Infection With Sepsis in the Elderly
Kristopher Ahn, MD
Medical Resident
Houston, Texas
Acute Hepatitis
Omowunmi Aibana, MD
Assistant Professor of Medicine
Houston, Texas
Anaphylaxis/Drug Reaction
Opioid Overdose
Madison Bangert, MD
Medical Resident
Houston, Texas
Acute hepatitis
Hemoptysis/Lung Cancer
Pancreatitis/Gallstones
Jammie Barnes, MD
Associate Professor of Medicine
Houston, Texas
Acute Monoarticular Arthritis—Gout
Rheumatoid Arthritis
vii

viii CONTRIBUTORS
Christopher Bertini, MS4

Medical Student
Houston, Texas
Adrenal Insufficiency
Type 2 Diabetes Diagnosis and Management
Manuscript Reviewer
Mac Bohanan, MS4
Medical Student
Houston, Texas
Immune Thrombocytopenic Purpura
Symptomatic Anemia and Transfusion Medicine
Jeffrey Chen, MD
Medical Resident
Houston, Texas
Immune Thrombocytopenic Purpura/Abnormal Bleeding
Symptomatic Anemia and Transfusion Medicine
Qingzheng Chen, MS4
Medical Student
Houston, Texas
Aortic Dissection/Marfan Syndrome
Heart Failure due to Critical Aortic Stenosis
Manuscript Reviewer
Sujith Cherian, MD
Houston, Texas
Chronic Obstructive Pulmonary Disease
Chronic Cough/Asthma
Pleural Effusion, Parapneumonic
Julia Chernis, MS4
Medical Student
Houston, Texas
Acute Monoarticular Arthritis—Gout
Osteoarthritis/Degenerative Joint Disease
Lead Manuscript Reviewer
Maneera T. Chopra, MS4
Medical Student
Houston, Texas
Acute Diverticulitis
Chronic Diarrhea
Manuscript Reviewer

CONTRIBUTORS ix
Amanda Clorfeine, MS4

Medical Student
Houston, Texas
Community-Acquired Pneumonia
Saumil Datar, MS4
Medical Student
Houston, Texas
Chronic Obstructive Pulmonary Disease
Chronic Cough/Asthma
Manuscript Reviewer
Jonathan Dau, MD
Medical Fellow
Houston, Texas
Neutropenic Fever in a Patient With Vascular Catheter Infection
Meningitis, Bacterial
Joy M. Davis, MS4
Medical Student
Houston, Texas
Review Questions
Olivia Drummond, MS4
Medical Student
Houston, Texas
Transient Ischemic Accident
Oligomenorrhea Caused by Hypothyroidism and Hyperprolactinemia
Kim Du, MS4
Medical Student
Houston, Texas
Thyrotoxicosis/Graves Disease
Manuscript Reviewer
Renee Flores, MS4
Medical Student
Houston, Texas
Iron-Deficiency Anemia
Parkinson Disease
John Foringer, MD
Professor of Medicine
Houston, Texas
Hypercalcemia/Multiple Myeloma
Hyponatremia, Syndrome of Inappropriate Secretion of Diuretic Hormone

x CONTRIBUTORS
Jinesh Gheeya, MD, PhD

Medical Resident
Houston, Texas
Acute Diverticulitis
Chronic Diarrhea
Rohit Goswamy, MD
Medical Resident
Houston, Texas
Parkinson Disease
Tuberculosis (Pulmonary), Cavitary Lung Lesions
Renato A. Guerrieri, MS4
Medical Student
Houston, Texas
Acute Glomerulonephritis
Painless Jaundice, Pancreatic Cancer
Manuscript Reviewer
Andrew Gulde, MS4
Medical Student
Houston, Texas
Acute Coronary Syndrome
Hypertension, Outpatient
Manuscript Reviewer
Absalon Gutierrez, MD
Houston, Texas
Adrenal Insufficiency
Oligomenorrhea Caused by Hypothyroidism and Hyperprolactinemia
Type 2 Diabetes Diagnosis and Management
Katie Guttenberg, MD
Houston, Texas
Osteoporosis, Cushing Syndrome
Carissa Huq, MD
Medical Resident
Houston, Texas
Liver Cirrhosis, Probably Alcoholic
Limb Ischemia (Peripheral Vascular Disease)
Peptic Ulcer Disease
Colitis and Inflammatory Bowel Disease

CONTRIBUTORS xi
Michael Hust, MD
Medical Fellow
Houston, Texas
Aortic Dissection/Marfan Syndrome
Heart Failure due to Aortic Stenosis
Marina Kristy Ibraheim, MS3
Medical Student
Houston, Texas
Diabetic Ketoacidosis, Type 1 Diabetes
Jill Jacoby, MD
Medical Resident
Houston, Texas
Iron-Deficiency Anemia
Aman Jaiswal, MS4
Medical Student
Houston, Texas
Manuscript Reviewer
Alyssa Kahl, MS4
Medical Student
Houston, Texas
Headache/Temporal Arteritis
Health Maintenance
Manuscript Reviewer
Maha Khalid, MS4
Medical Student
Houston, Texas
Pleural Effusion, Parapneumonic
Pulmonary Embolism
Manuscript Reviewer
Luana Kohnke, MS4
Medical Student
Houston, Texas
Atrial Fibrillation/Mitral Stenosis
Syncope and Heart Block
Manuscript Reviewer

xii CONTRIBUTORS
Alexandria Lawrence, MS4

Medical Student
Houston, Texas
Low Back Pain
Rheumatoid Arthritis
Manuscript Reviewer
Jeffrey Lofgran, MD
Houston, Texas
Atrial Fibrillation
Hypertensive Encephalopathy/Pheochromocytoma
Syncope and Heart Block
Urinary Tract Infection With Sepsis in the Elderly
Kristine McAndrews, MS4
Medical Student
Houston, Texas
Acute Kidney Injury
Nephrotic Syndrome and Diabetic Nephropathy
Manuscript Reviewer
Daniel McNavish, MS4
Medical Student
Houston, Texas
Pancreatitis/Gallstones
Hemoptysis/Lung Cancer
Manuscript Reviewer
Annika Medhus, MS4
Medical Student
Houston, Texas
Sickle Cell Crisis
Lauren Mellor-Crummey, MS4
Medical Student
Houston, Texas
Manuscript Reviewer
Avni Mody, MD
Medical Resident
Houston, Texas
Osteoporosis, Cushing Syndrome

CONTRIBUTORS xiii
Tyler Novy, MS3

Medical Student
Houston, Texas
Hypercalcemia/Multiple Myeloma
Hyponatremia, Syndrome of Inappropriate Secretion of Antidiuretic Hormone
Vivian Okirie, MD
Medical Resident
Houston, Texas
Community-Acquired Pneumonia
HIV/AIDS and Pneumocystis Pneumonia
Syphilis
Justin M. Olivas, MS4
Medical Student
Houston, Texas
Manuscript Reviewer
Elizabeth Park, MD
Houston, Texas
Diabetic Ketoacidosis, Type 1 Diabetes
Thyrotoxicosis/Graves Disease
Nicola Park, MS4
Medical Student
Houston, Texas
Pericardial Effusion/Tamponade Caused by Malignancy
Acute Pericarditis caused by Systemic Lupus Erythematosus
Anish Patnaik, MS4
Medical Student
Houston, Texas
Limb Ischemia (Peripheral Vascular Disease)
Manuscript Reviewer
Abin Puravath, MD
Medical Resident
Houston, Texas

xiv CONTRIBUTORS
Saher Rabadi, MD
Houston, Texas
Hypertension, Outpatient
Acute Coronary Syndrome
Nayana Ramachandra, MS4
Medical Student
Houston, Texas
Hypertensive Encephalopathy/Pheochromocytoma
Manuscript Reviewer
Chelsea T. Ratliff, MS4
Medical Student
Houston, Texas
Tuberculosis (Pulmonary), Cavitary Lung Lesions
Manuscript Reviewer
Tiffany Robles, MS4
Medical Student
Houston, Texas
Endocarditis (Tricuspid)/Septic Pulmonary Emboli
Daniel Rongo, MD
Medical Resident
Houston, Texas
Alzheimer Disease/Dementia
Delirium/Alcohol Withdrawal
Transient Ischemic Attack
Monica Rosales Santillan, MD
Medical Resident
Houston, Texas
Headache/Temporal Arteritis
Health Maintenance
Jennifer Swails, MD
Houston, Texas
Metabolic Syndrome
Polycythemia Vera

CONTRIBUTORS xv
Tuan Tang, MS4

Medical Student
Houston, Texas
Alzheimer Disease/Dementia
Manuscript Reviewer
Jade Teakell, MD
Houston, Texas
Acute Kidney Injury
Nephrotic Syndrome and Diabetic Nephropathy
Evangelia Valilis, MD
Medical Resident
Houston, Texas
Syphilis
Connor Vershel, MS4
Medical Student
Houston, Texas
Delirium/Alcohol Withdrawal
Manuscript Reviewer
Robby Wesley, MD
Houston, Texas
Acute Glomerulonephritis
Painless Jaundice, Pancreatic Cancer
Jacqueline Woloski, MS3
Medical Student
Houston, Texas
HIV/AIDS and Pneumocystis Pneumonia


PREFACE
I have been deeply amazed and grateful to see how the Case Files® books have
been so well received and have helped students to learn more effectively. In the 16
short years since Case Files® Internal Medicine was first printed, the series has now
multiplied to span most of the clinical and the basic science disciplines and has
been translated into over a dozen foreign languages. Numerous students have sent
encouraging remarks, suggestions, and recommendations. Six completely new cases
have been written. The cases have retained the organ system organization for bet-
ter ability to integrate knowledge. Case correlation references are also used in this
edition. This sixth edition has been a collaborative work with my wonderful coau-
thors and contributors and with the suggestions from six generations of students.
We utilized focus groups of students to create a more user-friendly format for the
digital platform, such as bullet points for the case summary for faster reading and
more plentiful use of subheadings throughout the text. We have used entrustable
professional activities (EPA) corresponding to the learning objectives. The multiple-
choice questions (MCQs) have been carefully reviewed and rewritten to ensure
that they comply with the National Board and the US Medical Licensing Examina-
tion format. Truly, the enthusiastic encouragement from students throughout not
only the United States but also the world provides me the inspiration and energy to
continue to write. It is thus with humility that I offer my sincere thanks to students
everywhere … for without students, how can a teacher teach?
Eugene C. Toy
xvii


ACKNOWLEDGMENTS
The curriculum that evolved into the ideas for this series was inspired by
Philbert Yau and Chuck Rosipal, two talented and forthright students, who have
since graduated from medical school. It has been a tremendous joy to work with my
excellent coauthor, Dr. Gabriel Aisenberg, who exemplifies the qualities of the ideal
physician—caring, empathetic, and avid teacher, and who is intellectually unparal-
leled. He had “big shoes” to fill in taking over from my dear friend and colleague
Dr. John Patlan, who has retired from academics and is currently in private practice.
We owe John a great debt for setting such a “high bar” with five excellent editions
of this book. Dr. Aisenberg would like to acknowledge Dr. Herbert Fred, a master
educator, teacher of the value of hard work and skepticism. Dr. Aisenberg and
I would like to express appreciation to Julia Chernis, who helped to coordinate
the assignment of cases and served as our student representative, including a thor-
ough student review for each case and careful reading of content, readability,
and questions/explanations. Julia is a special person and will succeed wherever she
goes. Julia would like to acknowledge Michael Kuhlmeier for his never-ending love
and support, as well as her amazing grandmother, Dr. Nadya Natanzon, whose
stories of her pediatric practice inspired her to pursue a career in medicine.
I am greatly indebted to Bob Boehringer, whose experience and vision helped to
support this series. I appreciate McGraw Hill’s believing in the concept of teach-
ing through clinical cases. I am also grateful to Catherine Saggese for her excel-
lent production expertise, and Madison Tucky for her wonderful and meticulous
role as editorial assistant. I cherish the ever-organized and precise project manager,
Sarika Gupta. It has been a privilege and honor to work with one of the brightest
medical students I have encountered, Joy Davis, who directed the review questions
and answers and gave input on the explanations for all the comprehension ques-
tions. As always, my daughter Allison serves as the assistant editor for the Case
Files Collection and has been meticulous and insightful concerning her review and
editing of this manuscript; she is like the key enzyme of the case files chemical
reactions, without whom all meaningful activity ceases and with whom the words
and concepts leap off the page with vigor and life. Most of all, I appreciate my
ever-loving wife, Terri, and our four wonderful children, Andy and his wife Anna,
Michael and his wife Nadine, Allison, and Christina and her husband Andy, for
their patience and understanding.
Eugene C. Toy
xix


INTRODUCTION
Mastering the cognitive knowledge within a field such as internal medicine is a

formidable task. It is even more difficult to draw on that knowledge, procure and
filter through the clinical and laboratory data, develop a differential diagnosis, and,
finally, make a rational treatment plan. To gain these skills, the student learns best
at the bedside, guided and instructed by experienced teachers, and inspired toward
self-directed, diligent reading. Clearly, there is no replacement for education at the
bedside. Unfortunately, clinical situations usually do not encompass the breadth of
the specialty. Perhaps the best alternative is a carefully crafted patient case designed
to stimulate the clinical approach and the decision-making process. In an attempt
to achieve that goal, we have constructed a collection of clinical vignettes to teach
diagnostic or therapeutic approaches relevant to internal medicine.
Most importantly, the explanations for the cases emphasize the mechanisms
and underlying principles, rather than merely rote questions and answers. This
book is organized for versatility: It allows the student “in a rush” to go quickly
through the scenarios and check the corresponding answers, and it allows the
student who wants thought-provoking explanations to obtain them. The answers
are arranged from simple to complex: the bare answers, an analysis of the case, an
approach to the pertinent topic, a comprehension test at the end, clinical pearls
for emphasis, and a list of references for further reading. The clinical vignettes are
organized by system to help students compare and contrast, and integrate infor-
mation. A listing of cases is included later in this section to aid the student who
desires to test his or her knowledge of a certain area, or to review a topic, including
basic definitions. Finally, we intentionally did not use a multiple-choice question
format in the case scenarios because clues (or distractions) are not available in the
real world.
HOW TO GET THE MOST OUT OF THIS BOOK

Each case is designed to simulate a patient encounter with open-ended questions.
At times, the patient’s complaint is different from the most concerning issue, and
sometimes extraneous information is given. The answers are organized into four
different parts, discussed next.
CLINICAL CASE FORMAT: PART I

1. Summary: The salient aspects of the case are identified, filtering out the extra-
neous information. Students should formulate their summary from the case
before looking at the answers. A comparison to the summation in the answer
will help to improve their ability to focus on the important data, while appro-
priately discarding the irrelevant information—a fundamental skill in clinical
problem-solving.
2. A straightforward Answer is given to each open-ended question.
xxi

xxii INTRODUC TION
Table 1 • SYNOPSIS OF ENTRUSTABLE PROFESSIONAL ACTIVITIES

EPA 1 Gather a history and perform a physical examination
EPA 2 Prioritize a differential diagnosis following a clinical encounter
EPA 3 Recommend and interpret common diagnostic and screening tests
EPA 4 Enter and discuss orders and prescriptions
EPA 5 Document a clinical encounter in the patient record
EPA 6 Provide an oral presentation of a clinical encounter
EPA 7 Form clinical questions and retrieve evidence to advance patient care
EPA 8 Give or receive a patient handover to transition care responsibly
EPA 9 Collaborate as a member of a interprofessional team
EPA 10 Recognize a patient requiring urgent or emergent care and initiate evaluation
and management
EPA 11 Obtain informed consent for tests and/or procedures
EPA 12 Perform general procedures as a physician
EPA 13 Identify system failures and contribute to a culture of safety and improvement
3. The Analysis of the case comprises two parts:

a. Objectives of the Case: A listing of the two or three main principles that
are crucial for a practitioner to manage the patient. Again, the students are
challenged to make educated “guesses” about the objectives of the case upon
initial review of the case scenario, which helps to sharpen their clinical and
analytical skills. We have included the entrustable professional activities
(EPA) corresponding to the objective for instructors and curriculum over-
seers (see Table 1).
b. Considerations: A discussion of the relevant points and brief approach to
the specific patient.
PART II
Approach to the Disease Process: It consists of two distinct parts:
a. Definitions: Terminology pertinent to the disease process.
b. Clinical Approach: A discussion of the approach to the clinical problem in
general, including tables, figures, and algorithms.
PART III
Comprehension Questions: Each case contains several multiple-choice questions,
which reinforce the material or which introduce new and related concepts. Ques-
tions about material not found in the text will have explanations in the answers.
PART IV
Clinical Pearls: Several clinically important points are reiterated as a summation of
the text. This allows for easy review, such as before an examination.

LISTING OF CASES
LISTING BY CASE NUMBER

CASE PAGE
NO. SYSTEM CASE TOPIC NUMBER
Wellness
1 Health Maintenance 22
2 Metabolic Syndrome 30
Cardiovascular
3 Acute Coronary Syndrome 40
4 Heart Failure due to Critical Aortic Stenosis 56
5 Aortic Dissection/Marfan Syndrome 66
6 Hypertension, Outpatient 76
7 Hypertensive Encephalopathy/
Pheochromocytoma 90
8 Atrial Fibrillation/Mitral Stenosis 100
9 Syncope and Heart Block 110
10 Acute Pericarditis Caused by Systemic
Lupus Erythematosus 119
11 Pericardial Effusion/Tamponade Caused by
Malignancy 126
12 Endocarditis (Tricuspid)/Septic Pulmonary
Emboli 134
13 Limb Ischemia (Peripheral Vascular Disease) 144
Pulmonary
14 Pulmonary Embolism 154
15 Chronic Obstructive Pulmonary Disease 164
16 Chronic Cough/Asthma 174
17 Pleural Effusion, Parapneumonic 185
18 Hemoptysis/Lung Cancer 194
19 Community-Acquired Pneumonia 204
Gastrointestinal
20 Peptic Ulcer Disease 214
21 Colitis and Inflammatory Bowel Disease 222
22 Acute Diverticulitis 232
23 Chronic Diarrhea 242
Hepatic, Gallbladder, Biliary
24 Liver Cirrhosis, Probably Alcoholic 256
xxiii

xxiv LISTING OF CASES
25 Pancreatitis/Gallstones 266
26 Acute Hepatitis 276
27 Painless Jaundice, Pancreatic Cancer 288
Renal, Genitourinary
28 Acute Glomerulonephritis 296
29 Nephrotic Syndrome and Diabetic
Nephropathy 306
30 Acute Kidney Injury 314
Musculoskeletal
31 Osteoarthritis/Degenerative Joint Disease 324
32 Low Back Pain 332
33 Acute Monoarticular Arthritis—Gout 342
34 Rheumatoid Arthritis 354
35 Osteoporosis, Cushing Syndrome 364
Neurological
36 Transient Ischemic Attack 378
37 Alzheimer Disease/Dementia 388
38 Headache/Temporal Arteritis 398
39 Parkinson Disease 406
Critical Care
40 Anaphylaxis/Drug Reactions 416
41 Urinary Tract Infection With Sepsis in
the Elderly 426
Immunological, Infectious
42 Vascular Catheter Infection in a Patient With
Neutropenic Fever 436
43 Meningitis, Bacterial 444
44 Tuberculosis (Pulmonary), Cavitary Lung
Lesions 457
45 Syphilis 466
46 HIV/AIDS and Pneumocystis Pneumonia 477
Endocrine/Hormonal
47 Hyponatremia, Syndrome of Inappropriate
Secretion of Antidiuretic Hormone 488
48 Oligomenorrhea Caused by Hypothyroidism
and Hyperprolactinemia 498
49 Adrenal Insufficiency 508
50 Hypercalcemia/Multiple Myeloma 517
51 Type 2 Diabetes Diagnosis and
Management 526
52 Diabetic Ketoacidosis, Type 1 Diabetes 536
53 Thyrotoxicosis/Graves Disease 548

LISTING OF CASES xxv
Hematological
54 Iron-Deficiency Anemia 558
55 Symptomatic Anemia and Transfusion
Medicine 570
56 Immune Thrombocytopenic Purpura/
Abnormal Bleeding 578
57 Polycythemia Vera 588
58 Sickle Cell Crisis 598
Alcohol Abuse/Toxicology
59 Delirium/Alcohol Withdrawal 606
60 Opioid Overdose 616
LISTING BY DISORDER (ALPHABETICAL)

PAGE
CASE NO. CASE TOPIC NUMBER
3 Acute Coronary Syndrome 40

22 Acute Diverticulitis 232
28 Acute Glomerulonephritis 296
26 Acute Hepatitis 276
30 Acute Kidney Injury 314
33 Acute Monoarticular Arthritis—Gout 342
10 Acute Pericarditis Caused by
Systemic Lupus Erythematosus 119
49 Adrenal Insufficiency 508
37 Alzheimer Disease/Dementia 388
40 Anaphylaxis/Drug Reactions 416
5 Aortic Dissection/Marfan Syndrome 66
8 Atrial Fibrillation/Mitral Stenosis 100
16 Chronic Cough/Asthma 174
23 Chronic Diarrhea 242
15 Chronic Obstructive Pulmonary Disease 164
21 Colitis and Inflammatory Bowel Disease 222
19 Community-Acquired Pneumonia 204
59 Delirium/Alcohol Withdrawal 606
52 Diabetic Ketoacidosis, Type 1 Diabetes 536
12 Endocarditis (Tricuspid)/Septic Pulmonary Emboli 134
38 Headache/Temporal Arteritis 398
1 Health Maintenance 22
4 Heart Failure due to Critical Aortic Stenosis 56

xxvi LISTING OF CASES
18 Hemoptysis/Lung Cancer 194

46 HIV/AIDS and Pneumocystis Pneumonia 477
50 Hypercalcemia/Multiple Myeloma 517
6 Hypertension, Outpatient 76
7 Hypertensive Encephalopathy/Pheochromocytoma 90
47 Hyponatremia, Syndrome of Inappropriate Secretion
of Antidiuretic Hormone 488
56 Immune Thrombocytopenic Purpura/Abnormal Bleeding 578
54 Iron-Deficiency Anemia 558
13 Limb Ischemia (Peripheral Vascular Disease) 144
24 Liver Cirrhosis, Probably Alcoholic 256
32 Low Back Pain 332
43 Meningitis, Bacterial 444
2 Metabolic Syndrome 30
29 Nephrotic Syndrome and Diabetic Nephropathy 306
48 Oligomenorrhea Caused by Hypothyroidism and
Hyperprolactinemia 498
60 Opioid Overdose 616
31 Osteoarthritis/Degenerative Joint Disease 324
35 Osteoporosis, Cushing Syndrome 364
27 Painless Jaundice, Pancreatic Cancer 288
25 Pancreatitis/Gallstones 266
39 Parkinson Disease 406
20 Peptic Ulcer Disease 214
11 Pericardial Effusion/Tamponade Caused by Malignancy 126
17 Pleural Effusion, Parapneumonic 185
57 Polycythemia Vera 588
14 Pulmonary Embolism 154
34 Rheumatoid Arthritis 354
58 Sickle Cell Crisis 598
55 Symptomatic Anemia and Transfusion Medicine 570
9 Syncope and Heart Block 110
45 Syphilis 466
53 Thyrotoxicosis/Graves Disease 548
36 Transient Ischemic Attack 378
44 Tuberculosis (Pulmonary), Cavitary Lung Lesions 457
51 Type 2 Diabetes Diagnosis and Management 526
41 Urinary Tract Infection With Sepsis in the Elderly 426
42 Vascular Catheter Infection in a Patient With
Neutropenic Fever 436

SECTION I
How to Approach
Clinical Problems
Part 1 Approach to the Patient

Part 2 Approach to Clinical Problem-Solving
Part 3 Approach to Reading
01_Toy_IM_Sec01_p001-018.indd 1 11/08/20 7:28 AM


SECTION I: HOW TO APPROACH CLINICAL PROBLEMS 3
Part 1. Approach to the Patient

The transition from the textbook or journal article to the clinical situation is one of
the most challenging tasks in medicine. Retention of information is difficult; orga-
nization of the facts and recall of myriad data in precise application to the patient
are crucial. The purpose of this text is to facilitate in this process. The first step is
gathering information, also known as establishing the database. This includes tak-
ing the history (asking questions), performing the physical examination, and
obtaining selective laboratory and/or imaging tests. Of these, the historical exami-
nation is the most important and useful. Sensitivity and respect should always be
exercised during the interview of patients.
CLINICAL PEARL
»» The history is the single most important tool in obtaining a diagnosis. All
physical findings and laboratory and imaging studies are first obtained
and then interpreted in the light of the pertinent history.
HISTORY
1. Basic information: Age, gender, and ethnicity must be recorded because some
conditions are more common at certain ages; for instance, pain on defecation
and rectal bleeding in a 20-year-old may indicate inflammatory bowel disease,
whereas the same symptoms in a 60-year-old would more likely suggest colon
cancer.
2. Chief complaint: What is it that brought the patient into the hospital or clinic?
Is it a scheduled appointment or an unexpected symptom? The patient’s own
words should be used if possible, such as, “I feel like a ton of bricks are on my
chest.” The chief complaint, or reason for seeking medical attention, may not
be the first subject the patient talks about (in fact, it may be the last thing),
particularly if the subject is embarrassing, such as a sexually transmitted dis-
ease, or highly emotional, such as depression. It is often useful to clarify exactly
what the patient’s concern is; for example, the patient may fear the headaches
represent an underlying brain tumor.
3. History of present illness: This is the most crucial part of the entire database.
The questions one asks are guided by the differential diagnosis one begins to
consider the moment the patient identifies the chief complaint, as well as the
clinician’s knowledge of typical disease patterns and their natural history. The
duration and character of the primary complaint, associated symptoms, and
exacerbating/relieving factors should be recorded. Sometimes, the history
will be convoluted and lengthy, with multiple diagnostic or therapeutic inter-
ventions at different locations. For patients with chronic illnesses, obtaining
prior medical records is invaluable. For example, when extensive evaluation of

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Mastering the cognitive knowledge within a field such as internal medicine is a

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A COMPANION GERMAN GRAMMAR. By H. de B. Gibbins, D.Litt.,