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The conceptual framework for this book is based on a traditional model of medical education: case-based learning. The case-based model is still very relevant, perhaps even more relevant, in the changing environment of physician training and education and advancing medical technology which combine to make it less likely that an individual physician will witness the evolution of a complex case from start to finish.

By understanding what happens in individual cases, one is able to generalize to similar situations and incorporate basic principles into practice. We are taught the classic signs and symptoms of innumerable diseases and disorders in the course of our medical training to develop skills in pattern recognition. From repetitive review of these patterns, we learn the elements of these common conditions. As the stages of medical education advance, one becomes more oriented to the expectations and, ultimately, exceptions in these routine patterns. It is appreciating the occurrence of deviations from this pattern, however minor, that leads to more advanced diagnostic skills. The astute physician detects variance from the typical pattern to make the more unusual or exceptional diagnosis.

In the education of pediatric house officers at the Children's Hospital of Philadelphia, there is a tradition of special rounds for the senior residents. The senior rounds are organized and conducted by the chief residents and supported by the faculty. It is within the context of these educational seminars that our residents are able to move and mature from pattern recognition to pattern deviation. We hope that in this effort they will move from good pediatricians to exceptional pediatricians.

This book represents a collection of many of those cases presented at the Children's Hospital of Philadelphia senior rounds. Most cases start with common complaints on the part of the child or parent. The cases presented in this text have common complaints, but, despite the protean presenting signs and symptoms, evolve into challenging diagnostic dilemmas. Each chapter in this book begins with a definition of a complaint, exploration of associated signs and symptoms that bring the patient to the physician, and discussion of questions associated with the complaint. The chapters then include a series of cases, each with twists and turns, that illustrate how to identify which children with common presenting complaints may have unusual or uncommon conditions. The cases are accompanied by clinical or radiologic images to enhance learning and retention. Following each case presentation, there is discussion of a broad differential diagnosis, commentary about which particular elements of that case led to the final diagnosis, and detailed discussion about the diagnosis in question, including epidemiology, signs and symptoms, diagnostic evaluation, and treatment.

For the book to be enjoyed most, we suggest the reader review each case and try to arrive at his or her own differential diagnosis and plan of evaluation, then read on and find out how the "mystery" was solved. An alternate way to use this book is to conduct your own group discussion or senior rounds by having one member of the group present a case and lead a discussion while using the text to facilitate dialogue.

Samir S. Shah
Stephen Ludwig

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