A 74-year-old man comes to your office because his wife and childrenhave noticed that his memory has become mildly impaired. He continuesto work part time in the family business. Recently, however, his daughter has found thathe is making significant errors with clients. For example, he has failed to show up for appointmentsthat he had scheduled, and has set up appointments with clients whom he has already served.Because of errors he has made in client billing, he has turned over the company’s bookkeepingresponsibilities to his daughter.

As a physician who specializes in pain management, I read with interest thearticle on chronic nonmalignant pain by Drs Atli and Loeser (CONSULTANT,November 2004, page 1693). Although the article was otherwise extremely informative,I was troubled by the authors’ failure to clarify the meaning of“breakthrough pain” in a nonmalignant setting and by their advocacy of theuse of short-acting opioids to treat such pain.

Use an otoscope earpiece duringcryotherapy to avoid injury to normalsurrounding tissue.

A 27-year-old woman is hospitalized after laboratory studies revealed extremelyelevated liver enzyme levels. The studies were ordered after the patient soughtmedical attention for severe headaches that began 3 weeks earlier and for thepast several days had been accompanied by malaise, nausea, and vomiting.

Lend a stethoscope to hard-of-hearingpatients who are not wearing a hearingaid.

To reduce discomfort when administeringpotassium in a peripheral line,mix in 2 mL of a 1% lidocaine solution.

A healthy 21-year-old man presented with a rapidly growing, filiform, ringshapedwart on his great toe (Figure).

Instead of throwing away the labelfrom an injectable medication, peel itoff and tape it to the patient’s chart.

I see patients with reflex sympathetic dystrophy (RSD) after industrial accidentsand for independent medical examinations.

This simple technique can quickly reduce leg edema.

My patient is a 70-year-old man who has had several episodesof cellulitis in his right thigh; he does not have diabetes.After the third episode, a 1-cm subcutaneous mass was excisedabove the area of recurrent cellulitis.

When treating a patient with an injuredhand, remove all rings as soonas possible.

A 66-year-old woman presents tothe emergency department(ED) with exertional dyspnea, generalizedweakness, and orthostaticdizziness; the symptoms startedabout 1 week earlier and have progressedinsidiously. The patient alsoreports diaphoresis and nausea withoutvomiting. She has no chest pain,palpitations, cough, or hemoptysis;she has not had a recent respiratorytract infection. While she is waitingto be admitted, she has an episode ofsyncope.

The continuous light projected intothe eye during a fundus examinationis unpleasant for patients.

For gynecologic examinations, coverstirrups with seasonally appropriatesocks that have patterns such ashearts, Christmas motifs, shamrocks,or American flags.

To expedite referrals, make multiplecopies of the letterhead of frequentlyused specialists.

I applaud Dr Anil Mandal’s 2 articleson edema (CONSULTANT, August2004, pages 1221 and 1245, respectively).

A 16-year-old boy presents with severe left shoulder pain that began 20 minutes earlier when heslipped while walking down an incline and attempted to prevent a fall by grabbing a nearby structurewith his left hand. As his body went forward, the left shoulder was abducted and externallyrotated. The accident caused him immediate pain, and any subsequent movement of the injuredshoulder increases the pain. Previously, the patient was healthy.

A 24-year-old man seeks medical attention 3 weeks after he injured his little finger playingfootball. He reports that the finger “came out of place” at the middle knuckle (proximal interphalangeal[PIP] joint); he quickly put the finger back into place himself, quit playing, andiced it. About 2 hours later, he was unable tomove the finger without significant pain, andthe following day, inability to move it interferedwith his performance of tasks that requiredfine manual dexterity. Since then, thepain has decreased, but the finger remainsswollen and he has not been able to fully extendit at the middle knuckle. In addition, thetip of the injured finger is hyperextended.

If elderly patients or those withchronic lung disease have troubleholding their breath in while you tryto listen for carotid bruits, have themtake a deep breath, exhale, and holdtheir breath out.