> A 69-year-old man was a heavy smoker and presented to his doctor with a
> painful, black big toe.  This was gangrenous on examination and he was
> admitted to hospital urgently for treatment and surgical amputation.  He
> made a good recovery and was well for a year.  He then started to develop
> pain in the lower back which came and went but was not severe enough to
> complain to his doctor.  On one occasion, however, he experienced
> excruciating pain in the lower right back and rapidly became shocked and
> collapsed with a pulse rate of 120/min and a systolic {*filter*} pressure of 60
> mmhg.  He was rushed to hospital but died in the ambulance.

> A postmortem examination was performed at which a large abdominal aneurysm
> was found ruptured.  There were 3 litres of fresh {*filter*} clot in the
> retroperitoneum, tracking up behind the right kidney.  The aorta showed
> severe atheroscierosis elsewhere.

> 1. How might you connect the episode of gangrene in the toe with the final
> pathology in this man?
> 2. What are the main risk factors for atheroscierosis?
> 3. What are the complications of an abdominal aortic aneurysm?

>A postmortem examination was performed at which a large abdominal aneurysm
>was found ruptured.  There were 3 litres of fresh {*filter*} clot in the
>retroperitoneum, tracking up behind the right kidney.  The aorta showed
>severe atheroscierosis elsewhere.

>1. How might you connect the episode of gangrene in the toe with the final
>pathology in this man?
>2. What are the main risk factors for atheroscierosis?
>3. What are the complications of an abdominal aortic aneurysm?

>Sounds suspiciously like homework to me....

> 1. How might you connect the episode of gangrene in the toe with the final
> pathology in this man?

> I was hoping that you folks could direct me to help tackle case studies.
> Like where do I begin, what are the obvious clues?, etc.....

> Okay, that puts an interesting slant on it.  Case studies usually
> force physicians in training to pursue one or more of four clinical
> questions: a) diagnosis b) therapy c) risk factor modification d)
> prognosis.   The approach to each of these are lectures in an of
> themselves but I will chat about diagnosis.  In my opinion,
> there are 6 ways to pursue a diagnosis:  a) statistical - what's
> most common in this epidemiological setting?, b) anatomical -
> what is the range of organs that rise to the problem
> (symptom/sign/abnormal lab or di finding) c) pathological - is
> the problem nutritional, metabolic, degerative, neoplastic,
> ischemic, inflammatory, endocrinological, infectious, iatrogenic,
> toxic, traumatic, psychological? d) physiological - good for
> considering the diagnosis of jaundice for example, e) pattern
> recognition - what comes to mind immediately? and f) no method.

> The usual approach for the beginner is consider one or more
> abnormalities and using a Boolean approach make a list of common
> associations using one or more of the diagnostic methods.  Once a
> list of possibilities is made, other facts are considered that
> help to rule in or rule out the diagnostic possibilities.
> There's no good way to tease out what is really important and
> what is less important early in training.  That is a matter of
> experience.

> Well, that's my approach.  I suspect there is no science to
> support it.

> Good luck.