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100 CASES

in Clinical Medicine

100 CASES

in Clinical Medicine

Second edition

P John Rees MD FRCP

Consultant Physician and Professor of Medical Education, King’s College London School of Medicine at Guy’s, King’s and St Thomas’ Hospitals, London, UK

James Pattison DM FRCP

Consultant Nephrologist, Guy’s and St Thomas’ NHS Foundation Trust,

London, UK

Gwyn Williams MD FRCP

Emeritus Professor of Medicine, King’s College London School of Medicine at Guy’s, King’s and St Thomas’ Hospitals, London, UK

First published in Great Britain in 2000 by Arnold This second edition published in 2007 by

Hodder Arnold, an imprint of Hodder Education and a member of the Hodder Headline Group, 338 Euston Road, London NW1 3BH

http://www.hoddereducation.com

Distributed in the United States of America by Oxford University Press Inc.,

198 Madison Avenue, New York, NY10016

Oxford is a registered trademark of Oxford University Press

© 2007 P John Rees, James M Pattison and Gwyn Williams

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronically or mechanically, including photocopying, recording or any information storage or retrieval system, without either prior permission in writing from the publisher or a licence permitting restricted copying. In the United Kingdom such licences are

issued by the Copyright Licensing Agency: Saffron House, 6-10 Kirby Street, London EC1N 8TS.

Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosage; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is

strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book.

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British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress

ISBN-10 0 340 92659 7

ISBN-13 978 0 340 92659 8

Typeset in 10/12 RotisSerif by Charon Tec Ltd (A MacMillan Company), Chennai, India www.charontec.com

Printed and bound in Spain

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CONTENTS

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PREFACE

Most doctors think that the most memorable way to learn medicine is to see patients. It is easier to recall information based on a real person than a page in a textbook. Another important element in the retention of information is the depth of learning. Learning that seeks to understand problems is more likely to be accessible later than superficial factual accumulation. This is the basis of problem-based learning, where students explore problems with the help of a facilitator. The cases in this book are designed to provide another useful approach, parallel to seeing patients and giving an opportunity for self-directed exploration of clinical problems. They are based on the findings of history taking and examination, together with the need to evaluate initial investigations such as blood investigations, X-rays and ECGs.

These cases are no substitute for clinical experience with real patients, but they provide a safe environment for students to explore clinical problems and their own approach to diagnosis and management. Most are common problems that might present to a general practitioner’s surgery, a medical outpatients or a session on call in hospital. There are a few more unusual cases to illustrate specific points and to emphasize that rare things do present, even if they are uncommon. The cases are written to try to interest students in clinical problems and to enthuse them to find out more. They try to explore thinking about diagnosis and management of real clinical situations.

The first 20 cases are arranged by systems, but the next 80 are in random order since, in medicine, symptoms such as breathlessness and pain may relate to many different clinical problems in various systems. We hope you enjoy working through the problems presented here and can put the lessons you learn into practice in your student and subsequent career.

P John Rees

James Pattison

Gwyn Williams

January 2007

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ACKNOWLEDGEMENTS

The authors would like to thank the following people for their help with illustrations: Dr A Saunders, Dr S Rankin, Dr J Reidy, Dr J Bingham, Dr L Macdonald, Dr G Cook, Dr T Gibson, Professor R Reznak, Dr B Lams, Dr J Chambers, Dr H Milburn and Dr J Gilmore.

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ABBREVIATIONS