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My own medical education began in earnest when I was able to relate the science of medicine to people – the individual cases that make up clinical practice. Their narratives brought medicine alive. As such experience builds, so too does the clinician’s awareness of the range of different presentations of even the commonest condition. The third edition of Clinical Problems in Medicine and Surgery exploits this ‘case-based learning’ approach to great effect. A carefully selected array of important clinical problems covering a broad range of medical and surgical conditions provide the substrate for questions that probe the reader’s understanding of the underlying pathology and, importantly, link the elements of the clinical reasoning process. The sequential approach adopted resonates with the intrinsic uncertainty of real clinical practice and the requirement to reassess as conditions change. Investigations, including imaging, are clearly presented. It is increasingly accepted that problem-based learning instills a deeper appreciation of principles. So too does a requirement to reiterate these same principles in a different context – here the Points for Revision sections will prove to be of great value to the student of medical practice. No compendium of clinical problems can ever be complete. But this is a compelling collection that can contribute much to the acquisition of clinical expertise. Importantly it is a stimulus to a rigorous reasoned approach to diagnosis and management, and the understanding of the scientific basis of medicine upon which sound medical practice depends. Professor Sir John Tooke

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THE PROBLEMS 1 Difficulties with postoperative fluid balance in a 58-year-old man

1 Richard J. Krysztopik

2 Postoperative fever  10 Wendy A. Brown

3 Postoperative hypotension  14 Paul C. Leeder and Sujad Kiani

4 Confusion in the postoperative ward  26 Toby T. Winton-Brown

5 Swelling in the neck in a 58-year-old man  32 Jonathan W. Serpell

6 A 42-year-old woman with hypertension  41 Lucia Gagliardi

7 A young woman with abnormal vaginal bleeding  49 Roger J. Pepperell

8 A scrotal swelling in a 27-year-old man  54 Jimmy Lam

9 A 63-year-old woman with a screen-detected abnormality  59 James Kollias

10 A 54-year-old man with a highvoltage electrical conduction injury  67 John E. Greenwood

11 Reflux in a 35-year-old man  76 Chris Deans and Andrew C. DeBeaux

12 Dysphagia and weight loss in a middle-aged man  84 Sarah K. Thompson

13 Abdominal pain in a young woman  93 Peter Devitt

14 A woman with acute upper abdominal pain  100 Duncan J. Stewart and Roger Ackroyd

15 Flank pain in a 60-year-old man  107 Darren Foreman Contents vi

16 Lower abdominal pain in a 77-year-old woman  113 Naseem Mirbagheri and Stewart Skinner

17 Nausea and constipation in an older woman  119 Robert Ludemann

18 A lady with diarrhoea and abdominal pain  125 Jonathan Mitchell and Philip Clelland

19 Rectal bleeding in a 45-year-old woman  135 James Sweeney

20 Haematuria in a 60-year-old man  143 Darren Foreman

21 The routine check-up  149 Jimmy Lam

22 Acute back pain in a 75-year-old man  154 Robert Fitridge

23 A 59-year-old man with calf pain  159 Robert Fitridge

24 Acute leg pain in a 73-year-old man  166 Robert Fitridge

25 A 68-year-old woman with a leg ulcer  172 Robert Fitridge

26 A 41-year-old man involved in a car crash  176 Andrew W. Perry

27 Management of acute coronary syndrome 183 Matthew Pincus

28 Breathlessness in a young woman  190 David Platts

29 A 25-year-old woman with chest pain and breathlessness  198 Fiona Kermeen

30 Recurrent collapse in a 56-year-old truck driver  206 Jamie Layland

31 A 68-year-old woman with breathlessness and yellow sputum  213 Hubertus P.A. Jersmann

32 Persistent cough in a young woman  222 Richard A. Stapledon

33 Cough, dyspnoea and fever in a 55-year-old man  228 Narin Bak

34 Breathlessness and weight loss in a 58-year-old man  234 Hubertus P.A. Jersmann

35 A 35-year-old woman vomiting blood 243 Jonathan Mitchell

36 A young woman with jaundice  250 Usama Warshow

37 A 47-year-old man with lethargy and hypertension  257 Mark Gilchrist

38 A 35-year-old woman with hypertension  262 Anne Tonkin

39 A young man with depressed conscious state and seizures  271 Michelle Kiley Contents vii

40 A middle-aged man with sudden visual loss  278 Sumu Simon and Robert Fitridge

41 ‘Jack has leg weakness’  284 Gabriel Lee

42 Fall during a fishing weekend  289 Andrew Zacest

43 An unwell young man in the emergency room  295 Jonathan Mitchell and Mohammed M. Rashid

44 A 68-year-old woman with a left hemiplegia following a conscious collapse  304 Timothy Kleinig

45 A 31-year-old woman with vertigo  311 Timothy Kleinig

46 A 31-year-old man with sudden onset headache and vomiting  317 Andrew Zacest

47 Fatigue and bruising in a teenager  322 Charles G. Mullighan

48 Severe dehydration in a young woman  328 Sanghamitra Guha

49 A woman with palpitations  336 David Torpy

50 A collapsed, breathless woman  343 Andrew W. Perry

51 Management of a young man who is HIV positive  350 Karen E. Rowland

52 Back and leg pain in a middle-aged man  357 Gabriel Lee

53 Acute respiratory failure in a 68-year-old man  362 Stephen W. Lam

54 A listless 45-year-old man  371 Cyril Sieberhagen and Jonathan Mitchell

55 A 74-year-old man with confusion and oliguria  378 Randall F

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