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 information. 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 extraneous 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 appropriately discarding the irrelevant information—a fundamental skill in clinical problem-solving.

2. A straightforward Answer is given to each open-ended question.

3. The Analysis of the case comprises two parts:

1. 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 overseers (see Table 1).

2. 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:

1. Definitions: Terminology pertinent to the disease process.

2. 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. Questions 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.