250 Cases in Clinical Medicine, 4th Edition pdf


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The current edition of the book has been updated to reflect the new expec
tations of the Royal College of Physicians and its examiners. The practice

of clinical medicine requires ‘connecting-the-dots’ across pieces of infor-
mation; that is, it requires utilization of both verbatim memory and gist

memory (JAMA, 2009;302:1332–1333). Verbatim memory involves mere
recollection of facts (e.g. causes of pleural fluid) whereas gist memory
involves interpretation (e.g. that a very low pleural fluid glucose in a
patient with inflamed joints indicates that rheumatoid arthritis may be the
cause of pleural effusion). Clinical examinations have been redesigned to
reflect the day-to-day practice of clinical medicine. Therefore, success in
clinical examinations requires development of both forms of memory.
Astute clinicians utilize such gist-based reasoning to arrive at the right
diagnosis, and their clinical reasoning is superior because they are able to
recognize the gist of clinical symptoms: clinical examinations are designed
to identify this competency. This edition has been updated keeping in
mind these new expectations. More cases now have representative pictures

to enhance gist memory to help a prospective candidate to ‘connect-the-
dots’ in the examination situation in a timely fashion; the text provides

material to improve verbatim memory.

Although this book is designed for the clinical examination it is best uti-
lized at least 6 months before the Part 1 MRCP written examination and

at least a year before the PACES clinical examination. Simultaneous devel-
opment of both gist and verbatim memory requires a lot of practice and,

therefore, this book is best utilized at the bedside after seeing an index
case. To improve gist memory by only seeing patients (without using this
book) is like embarking on a trans-Atlantic flight without a flight plan,
but merely to read books without seeing adequate numbers of patients is
like a plane not taking off at all. Each candidate is encouraged not only
to see at least three to four representative patients of each case but also
to present each patient to a colleague who has passed the examination or
a consultant physician (i.e. each case should have been presented by the
candidate at least three to four times before the examination); style matters
as much as substance and this requires practise, practise and more
This book should continue to be useful for MBBS, PLAB, LRCP, MRCP
(UK), MRCPI, postgraduate clinical examinations in the US, Australia

(FRACP) and Canada (FCCP), and MD (New Zealand, Malaysia, Singa-
pore, India, Pakistan, Sri Lanka and Bangladesh). The current organization

of this book should also be appropriate for medical students in the US

taking the USMLE and for the American Board of Internal Medicine Exam-
ination (ABIM). Cases for examinations are drawn from the same pool for

both undergraduate and postgraduate examinations, although in the latter
the candidate’s performance has to be faultless and he or she will be
expected to know certain aspects in greater detail.

Preface: ‘connecting-the-dots’

250 Cases in Clinical Medicine
Each case is discussed under a number of headings.
Instruction: this allows the candidate to know what sort of instruction or
command may be expected from an examiner.
Salient features: this section includes important features in each case
including aspects in history, physical signs, guidelines on how to
proceed when faced with these signs and what to tell the examiner, in
order to satisfy the examiner that the candidate is ‘safe and sound’ to be
a competent clinician.

Diagnosis: most candidates are unable to present their diagnosis in a suc-
cinct manner, although they are able to elicit the clinical signs. This

heading has been included to help candidates to present their diagnosis
in a crisp and confident fashion.

Questions: this section supplies the questions (with answers) that a can-
didate can expect in a given case. These are also useful for the viva

component of the examination.

Endnotes: many of the cases have endnotes giving historical aspects rel-
evant to that particular case, and some have key review references.

Although examiners will not deduct marks for ignorance of things that
have little relevance to patient welfare, candidates who know the facts
can expect a congratulatory glow to pervade the examiner, so that the
rest of the questions may be softened accordingly.


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