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 SIXTH EDITION

CASE FILES®
Internal Medicine
Eugene C. Toy, MD Gabriel M. Aisenberg, MD
Assistant Dean for Educational Programs Associate Professor of Medicine
Director of Doctoring Courses Department of General Internal Medicine
Professor and Vice Chair of Medical Education McGovern Medical School at The University
Department of Obstetrics and Gynecology of Texas
McGovern Medical School at The University Health Science Center at Houston (UTHealth)
of Texas Houston, Texas
Health Science Center at Houston (UTHealth)
Houston, Texas

New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto

00_Toy-IM_FM_p000i-xxvi.indd 1 04/09/20 3:26 PM

Copyright © 2021 by McGraw Hill. All rights reserved. Except as permitted under the United States Copyright
Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored
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 DEDICATION

To the McGovern Medical School class of 2020,

who have continued to challenge and inspire me to be the
very best teacher possible. You are the first class of our new curriculum,
and you trusted that the theoretical dreams
and abstract fancies weaving the basic and clinical sciences with the art
of medicine in the Doctoring Courses would work. Four years later,
we know it worked, primarily because each of you believed
and worked diligently to fill in the gaps that we missed.
You are each what is most special about medicine and are the reason I teach.
May you have a wonderfully fulfilling and
rewarding career, and continue to learn and heal.
—ECT
To my beloved wife, Cynthia, and my children, Lucas, Tomas, and
Carola, whose support, love, and understanding fill me
with hope, with energy, and with passion. To Dr. Herbert L. Fred,
a mentor and a friend. He may not be around,
but his light will shine forever.
—GA

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 This page intentionally left blank

00_Toy-IM_FM_p000i-xxvi.indd 4 04/09/20 3:26 PM

 CONTENTS

Contributors / vii
Preface / xvii
Acknowledgments / xix
Introduction / xxi
Listing of Cases / xxiii

Section I
How to Approach Clinical Problems....................................................................1
Part 1. Approach to the Patient.................................................................................................. 3
Part 2. Approach to Clinical Problem-Solving.....................................................................10
Part 3. Approach to Reading.....................................................................................................13

Section II
Clinical Cases.......................................................................................................19
Wellness (Cases 1-2).................................................................................................................21
Cardiovascular (Cases 3-13)..................................................................................................39
Pulmonary (Cases 14-19).................................................................................................... 153
Gastrointestinal (Cases 20-23).......................................................................................... 213
Hepatic, Gallbladder, Biliary (Cases 24-27)................................................................... 255
Renal, Genitourinary (Cases 28-30)................................................................................. 295
Musculoskeletal (Cases 31-35).......................................................................................... 323
Neurological (Cases 36-39)................................................................................................. 377
Critical Care (Cases 40-41).................................................................................................. 415
Immunological, Infectious (Cases 42-46)...................................................................... 435
Endocrine/Hormonal (Cases 47-53)................................................................................ 487
Hematological (Cases 54-58)............................................................................................. 557
Alcohol Abuse/ Toxicology (Case 59-60)....................................................................... 605

Section III
Review Questions....................................................................................................................... 627

Index / 641

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 This page intentionally left blank

00_Toy-IM_FM_p000i-xxvi.indd 6 04/09/20 3:26 PM

 CONTRIBUTORS

Radhini Abeysekera, MS4

Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Meningitis, Bacterial
Vascular Catheter Infection in a Patient With Neutropenic Fever
Heba Ahmad, MS3
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Anaphylaxis/Drug Reactions
Urinary Tract Infection With Sepsis in the Elderly
Kristopher Ahn, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Acute Hepatitis
Omowunmi Aibana, MD
Assistant Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Anaphylaxis/Drug Reaction
Opioid Overdose
Madison Bangert, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Acute hepatitis
Hemoptysis/Lung Cancer
Pancreatitis/Gallstones
Jammie Barnes, MD
Associate Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Acute Monoarticular Arthritis—Gout
Rheumatoid Arthritis

vii

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 viii CONTRIBUTORS

Christopher Bertini, MS4

Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Adrenal Insufficiency
Type 2 Diabetes Diagnosis and Management
Manuscript Reviewer
Mac Bohanan, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Immune Thrombocytopenic Purpura
Symptomatic Anemia and Transfusion Medicine
Jeffrey Chen, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Immune Thrombocytopenic Purpura/Abnormal Bleeding
Symptomatic Anemia and Transfusion Medicine
Qingzheng Chen, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Aortic Dissection/Marfan Syndrome
Heart Failure due to Critical Aortic Stenosis
Manuscript Reviewer
Sujith Cherian, MD
Assistant Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Chronic Obstructive Pulmonary Disease
Chronic Cough/Asthma
Pleural Effusion, Parapneumonic
Julia Chernis, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Acute Monoarticular Arthritis—Gout
Osteoarthritis/Degenerative Joint Disease
Lead Manuscript Reviewer
Maneera T. Chopra, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Acute Diverticulitis
Chronic Diarrhea
Manuscript Reviewer

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 CONTRIBUTORS ix

Amanda Clorfeine, MS4

Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Community-Acquired Pneumonia
Saumil Datar, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Chronic Obstructive Pulmonary Disease
Chronic Cough/Asthma
Manuscript Reviewer
Jonathan Dau, MD
Medical Fellow
McGovern Medical School at UTHealth in Houston
Houston, Texas
Neutropenic Fever in a Patient With Vascular Catheter Infection
Meningitis, Bacterial
Joy M. Davis, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Review Questions
Olivia Drummond, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Transient Ischemic Accident
Oligomenorrhea Caused by Hypothyroidism and Hyperprolactinemia
Kim Du, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Thyrotoxicosis/Graves Disease
Manuscript Reviewer
Renee Flores, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Iron-Deficiency Anemia
Parkinson Disease
John Foringer, MD
Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Hypercalcemia/Multiple Myeloma
Hyponatremia, Syndrome of Inappropriate Secretion of Diuretic Hormone

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 x CONTRIBUTORS

Jinesh Gheeya, MD, PhD

Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Acute Diverticulitis
Chronic Diarrhea
Rohit Goswamy, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Parkinson Disease
Tuberculosis (Pulmonary), Cavitary Lung Lesions
Renato A. Guerrieri, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Acute Glomerulonephritis
Painless Jaundice, Pancreatic Cancer
Manuscript Reviewer
Andrew Gulde, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Acute Coronary Syndrome
Hypertension, Outpatient
Manuscript Reviewer
Absalon Gutierrez, MD
Associate Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Adrenal Insufficiency
Oligomenorrhea Caused by Hypothyroidism and Hyperprolactinemia
Type 2 Diabetes Diagnosis and Management
Katie Guttenberg, MD
Assistant Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Osteoporosis, Cushing Syndrome
Carissa Huq, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Liver Cirrhosis, Probably Alcoholic
Limb Ischemia (Peripheral Vascular Disease)
Peptic Ulcer Disease
Colitis and Inflammatory Bowel Disease

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 CONTRIBUTORS xi

Michael Hust, MD
Medical Fellow
McGovern Medical School at UTHealth in Houston
Houston, Texas
Aortic Dissection/Marfan Syndrome
Heart Failure due to Aortic Stenosis
Marina Kristy Ibraheim, MS3
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Diabetic Ketoacidosis, Type 1 Diabetes
Jill Jacoby, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Iron-Deficiency Anemia
Aman Jaiswal, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Manuscript Reviewer
Alyssa Kahl, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Headache/Temporal Arteritis
Health Maintenance
Manuscript Reviewer
Maha Khalid, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Pleural Effusion, Parapneumonic
Pulmonary Embolism
Manuscript Reviewer
Luana Kohnke, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Atrial Fibrillation/Mitral Stenosis
Syncope and Heart Block
Manuscript Reviewer

00_Toy-IM_FM_p000i-xxvi.indd 11 04/09/20 3:26 PM

 xii CONTRIBUTORS

Alexandria Lawrence, MS4

Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Low Back Pain
Rheumatoid Arthritis
Manuscript Reviewer
Jeffrey Lofgran, MD
Assistant Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Atrial Fibrillation
Hypertensive Encephalopathy/Pheochromocytoma
Syncope and Heart Block
Urinary Tract Infection With Sepsis in the Elderly
Kristine McAndrews, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Acute Kidney Injury
Nephrotic Syndrome and Diabetic Nephropathy
Manuscript Reviewer
Daniel McNavish, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Pancreatitis/Gallstones
Hemoptysis/Lung Cancer
Manuscript Reviewer
Annika Medhus, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Sickle Cell Crisis
Lauren Mellor-Crummey, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Manuscript Reviewer
Avni Mody, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Osteoporosis, Cushing Syndrome

00_Toy-IM_FM_p000i-xxvi.indd 12 04/09/20 3:26 PM

 CONTRIBUTORS xiii

Tyler Novy, MS3

Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Hypercalcemia/Multiple Myeloma
Hyponatremia, Syndrome of Inappropriate Secretion of Antidiuretic Hormone
Vivian Okirie, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Community-Acquired Pneumonia
HIV/AIDS and Pneumocystis Pneumonia
Syphilis
Justin M. Olivas, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Peptic Ulcer Disease
Colitis and Inflammatory Bowel Disease
Manuscript Reviewer
Elizabeth Park, MD
Assistant Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Diabetic Ketoacidosis, Type 1 Diabetes
Thyrotoxicosis/Graves Disease
Nicola Park, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Pericardial Effusion/Tamponade Caused by Malignancy
Acute Pericarditis caused by Systemic Lupus Erythematosus
Anish Patnaik, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Limb Ischemia (Peripheral Vascular Disease)
Manuscript Reviewer
Abin Puravath, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Peptic Ulcer Disease
Colitis and Inflammatory Bowel Disease

00_Toy-IM_FM_p000i-xxvi.indd 13 04/09/20 3:26 PM

 xiv CONTRIBUTORS

Saher Rabadi, MD
Assistant Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Hypertension, Outpatient
Acute Coronary Syndrome
Nayana Ramachandra, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Hypertensive Encephalopathy/Pheochromocytoma
Manuscript Reviewer
Chelsea T. Ratliff, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Tuberculosis (Pulmonary), Cavitary Lung Lesions
Manuscript Reviewer
Tiffany Robles, MS4
Medical Student
McGovern Medical School at UTHealth in Houston
Houston, Texas
Endocarditis (Tricuspid)/Septic Pulmonary Emboli
Daniel Rongo, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Alzheimer Disease/Dementia
Delirium/Alcohol Withdrawal
Transient Ischemic Attack
Monica Rosales Santillan, MD
Medical Resident
McGovern Medical School at UTHealth in Houston
Houston, Texas
Headache/Temporal Arteritis
Health Maintenance
Jennifer Swails, MD
Associate Professor of Medicine
McGovern Medical School at UTHealth in Houston
Houston, Texas
Metabolic Syndrome
Polycythemia Vera

00_Toy-IM_FM_p000i-xxvi.indd 14 04/09/20 3:26 PM

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 Transcriber’s Notes
Obvious errors in punctuation and inconsistencies in proper names have been silently
corrected.
Page 17: “he rest of Europe” changed to “the rest of Europe”
Page 263: “Bogdanóvich’s Pysche” changed to “Bogdanóvich’s Psyche”
Page 313: “shine in the bark” changed to “shine in the dark”
Page 315: “mary him” changed to “marry him”
Page 321: “aphabetical order” changed to “alphabetical order”
Page 352: “more stupid that our” changed to “more stupid than our”
Page 418: “are overthown” changed to “are overthrown”
Page 438: “learny our parts” changed to “learn our parts”
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