THIRD EDITION CASE FILES ® Internal Medicine Eugene C. Toy, MD The John S. Dunn, Senior Academic Chair and Program Director The Methodist Hospital Ob/Gyn Residency Program Houston, Texas Vice Chair of Academic Affairs Department of Obstetrics and Gynecology The Methodist Hospital Houston, Texas Associate Clinical Professor and Clerkship Director Department of Obstetrics and Gynecology University of Texas Medical School at Houston Houston, Texas Associate Clinical Professor Weill Cornell College of Medicine John T. Patlan, Jr., MD Assistant Professor of Medicine Department of General Internal Medicine MD Anderson Cancer Center Houston, Texas New York Chicago San Francisco Lisbon London Madrid Mexico City Milan New Delhi San Juan Seoul Singapore Sydney Toronto Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved. 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Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or cause arises in contract, tort or otherwise. DEDICATION Toour coach Victor, and our father–son teammates Bob & Jackson, Steve & Weston, Ron & Wesley, and Dan & Joel. At the inspirational JH Ranch Father–Son Retreat, all of us, including my loving son Andy, arrived as strangers, but in 6 days, we left as lifelong friends. — ECT To my parents who instilled an early love of learning and of the written word, and who continue to serve as role models for life. To my beautiful wife Elsa and children Sarah and Sean, for their patience and understanding, as precious family time was devoted to the completion of “the book.” To all my teachers, particularly Drs. Carlos Pestaña, Robert Nolan, Herbert Fred, and Cheves Smythe, who make the complex understandable, and who have dedicated their lives to the education of physicians, and served as role models of healers. To the medical students and residents at the University of Texas–Houston Medical School whose enthusiasm, curiosity, and pursuit of excellent and compassionate care provide a constant source of stimulation, joy, and pride. To all readers of this book everywhere in the hopes that it might help them to grow in wisdom and understanding, and to provide better care for their patients who look to them for comfort and relief of suffering. And to the Creator of all things, Who is the source of all knowledge and healing power, may this book serve as an instrument of His will. — JTP This page intentionally left blank CONTENTS Contributor / vii Acknowledgments / ix Introduction / xi Section I How to Approach Clinical Problems . . . . . . . . . . . . . . . . . . . . .1 Part 1. Approach to the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Part 2. Approach to Clinical Problem Solving . . . . . . . . . . . . . . . . . . . . . . .9 Part 3. Approach to Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Section II Clinical Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Sixty Case Scenarios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Section III Listing of Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .549 Listing by Case Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .551 Listing by Disorder (Alphabetical) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .552 Index / 555 This page intentionally left blank CONTRIBUTOR Molly Dudley Class of 2009 University of Texas Health Science Center at San Antonio San Antonio, Texas Approach to congestive heart failure Approach to HIV and pneumocystits pneumonia Approach to hypertension Approach to Arthritis Approach to low back pain Approach to endocarditis Approach to lung disease Approach to lung cancer Approach to health maintenance vii This page intentionally left blank 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 coauthors, especially Dr. John Patlan, who exemplifies the qualities of the ideal physician—caring, empathetic, and avid teacher, and who is intellectually unparalleled. I am greatly indebted to my editor, Catherine Johnson, whose exuberance, experience, and vision helped to shape this series. I appreciate McGraw-Hill’s believing in the concept of teaching through clinical cases. I am also grateful to Catherine Saggese for her excellent production expertise, and Cindy Yoo for her wonderful editing. I cherish the ever-organized and precise Gita Raman, senior project manager, whose friend- ship and talent I greatly value; she keeps me focused, and nurtures each of my books from manuscript to print. It has been a privilege and honor to work with one of the brightest medical students I have encountered, Molly Dudley who was the principal student reviewer of this book. She enthusiastically provided feedback and helped to emphasize the right material. I appreciate Dorothy Mersinger and Jo McMains for their sage advice and support. At Methodist, I appreciate Drs. Judy Paukert, Dirk Sostman, Marc Boom and Alan Kaplan who have welcomed our residents; John N. Lyle VII, a brilliant administrator and Barbara Hagemeister, who holds the department together. Without my dear colleagues, Drs. Weilie Tjoa, Juan Franco, Waverly Peakes, Nicolas Stephanou, and Vincente Zapata, this book could not have been written. Most of all, I appreciate my ever-loving wife Terri, and our four wonderful children, Andy, Michael, Allison, and Christina, for their patience and understanding. Eugene C. Toy ix