In the previous two volumes of this series, we presented classic problems in internal medicine as illustrated by actual cases cared for in our institution. It has been gratifying for us to see the interest that these volumes have generated with students and trainees. We remain committed to the case method of instruction, and believe that there is no better method to learn medicine than to have an individual patient problem as the basis for study of pathophysiology, natural history, diagnosis and management. We hope that our readers find this third volume as enjoyable and instructive as the editors found it. Juan M. Bowen, MD Ernest L. Mazzaferri, MD, FACP xiii Acknowledgement The editors are grateful to Jeff Smith and Jenny Riegler for their unflagging professionalism and patience. xiv Contents Case 1 Mitral Regurgitation - Chronic Versus Acute: Implications for Timing of Surgery • . • • • . . • . . . . . • . . . . . . . . . . . 1 Harisios Boudoulas, MD Charles F. Wooley, MD Advances and diagnostic imaging in a surgical technique have changed the approach to mitral valve regurgitation. This chapter provides an expert's perspective. Case 2 Cystic Fibrosis in Adults .. • •••••••••••• 36 Andrew Libertin, MD John S. Heintz, MD As children with cystic fibrosis grow into adulthood, the internist assumes a greater role in their care. Case 3 Thrombotic Thrombocytopenic Purpura . . . . . . . . . . 51 . . . Donald E. Thornton, MD Earl N. Metz, MD, FACP Patients with ITP continue to present difficulties in diagnosis and management. Two experts discuss the current approach to ITP.

Read with two objectives: first, to acquaint yourself with the current knowledge of a subject and the steps by which it has been reached; and secondly, and more important, read to understand and analyze your cases. William Osler, The Student Life What follows is a collection of cases-or more aptly, the stories of our patients and friends who have been seen at The Ohio State University Hospitals where our faculty have provided their care and about whom this volume is written. Today many fear that our patients are being moved from center stage while we are being distracted by the technology of medicine. This volume was written with patients in mind. The idea is that the most intriguing questions and the most rewarding answers begin and end at the bedside. This is a story of our patients, told by expert clinicians and spiced with commentary along the way. This volume in no way at­ tempts to be comprehensive. Instead, it is like the practice of medicine, scattered, somewhat disjointed, while at the same time intensely personal and focused upon whatever problem the patient brings to us. The discussions are not so much about disease entities as they are about patients with problem". The two are uniquely dif­ ferent. For instance, when the physician suspects hepatitis, not every imaginable cause can be actively investigated. Instead, tests and procedures are discriminate­ ly chosen, a part of medicine that is still more art than science.

In the previous two volumes of this series, we presented classic problems in internal medicine as illustrated by actual cases cared for in our institution. It has been gratifying for us to see the interest that these volumes have generated with students and trainees. We remain committed to the case method of instruction, and believe that there is no better method to learn medicine than to have an individual patient problem as the basis for study of pathophysiology, natural history, diagnosis and management. We hope that our readers find this third volume as enjoyable and instructive as the editors found it. Juan M. Bowen, MD Ernest L. Mazzaferri, MD, FACP xiii Acknowledgement The editors are grateful to Jeff Smith and Jenny Riegler for their unflagging professionalism and patience. xiv Contents Case 1 Mitral Regurgitation - Chronic Versus Acute: Implications for Timing of Surgery • . • • • . . • . . . . . • . . . . . . . . . . . 1 Harisios Boudoulas, MD Charles F. Wooley, MD Advances and diagnostic imaging in a surgical technique have changed the approach to mitral valve regurgitation. This chapter provides an expert's perspective. Case 2 Cystic Fibrosis in Adults .. • •••••••••••• 36 Andrew Libertin, MD John S. Heintz, MD As children with cystic fibrosis grow into adulthood, the internist assumes a greater role in their care. Case 3 Thrombotic Thrombocytopenic Purpura . . . . . . . . . . 51 . . . Donald E. Thornton, MD Earl N. Metz, MD, FACP Patients with ITP continue to present difficulties in diagnosis and management. Two experts discuss the current approach to ITP.

Read with two objectives: first, to acquaint yourself with the current knowledge of a subject and the steps by which it has been reached; and secondly, and more important, read to understand and analyze your cases. William Osler, The Student Life What follows is a collection of cases-or more aptly, the stories of our patients and friends who have been seen at The Ohio State University Hospitals where our faculty have provided their care and about whom this volume is written. Today many fear that our patients are being moved from center stage while we are being distracted by the technology of medicine. This volume was written with patients in mind. The idea is that the most intriguing questions and the most rewarding answers begin and end at the bedside. This is a story of our patients, told by expert clinicians and spiced with commentary along the way. This volume in no way at­ tempts to be comprehensive. Instead, it is like the practice of medicine, scattered, somewhat disjointed, while at the same time intensely personal and focused upon whatever problem the patient brings to us. The discussions are not so much about disease entities as they are about patients with problem". The two are uniquely dif­ ferent. For instance, when the physician suspects hepatitis, not every imaginable cause can be actively investigated. Instead, tests and procedures are discriminate­ ly chosen, a part of medicine that is still more art than science.