An 84-year-old woman presents with a 3-year history of slowly progressivememory impairment accompanied by functional decline. Thepatient lives alone but has been receiving an increasing amount of support from her 2 daughters,who accompany her to the appointment. The daughters first noticed that their mother was havingtrouble driving. About a year ago, she started forgetting family recipes. She also left food cookingon the stove unattended and burned several pans. Currently, the daughters are providing mealsand transportation, assisting with housework, and doing their mother’s laundry. They have becomeincreasingly alarmed because she takes her medications only sporadically, despite the factthat they fill her pillboxes and call her regularly with reminders. Their chief concern is whether itis safe for their mother to continue to live alone.

For 3 months, a 57-year-old woman has had a persistent green nail that is occasionallyslightly sore; the nail plate has lifted. Another physician prescribed a7-day course of levofloxacin for a suspected Pseudomonas infection; the treatmenthad no effect on the nail. A subsequent 7-day course of norfloxacin wasalso unsuccessful. The patient is otherwise healthy.

For the past 2 days, an elderly woman has had severe pain in and discharge from the right ear. She has diabetes, which is well controlled with anoral hypoglycemic agent, and eczematous dermatitis.

A 17-year-old girl who is a competitive cross-country runner presentswith exercise-induced pain in the lower left leg that hasbeen present for 2 months. She describes the pain as a feelingof tightness that begins after 20 to 30 minutes of running; thistightness usually resolves within 15 to 30 minutes after shestops. During the past 3 weeks, the tightness has been accompaniedby a cramp-like pain. The patient runs before and afterschool about 12 miles each day. In addition to running, she hasalso begun playing flag football during the past 2 weeks. She isotherwise in good health.

A 41-year-old woman with a 4-yearhistory of polymyositis with lupus featureshas had constant rectal pain for4 months. She has not noticed any factorsthat either aggravate or relievethe pain. The patient complains of intermittentconstipation (but no dischargeor rectal bleeding), generalizedweakness and malaise for the past 2months, a low-grade fever for the pastmonth, and a 4.1-kg (9-lb) weight lossover the past 6 weeks. She denies nightsweats or chills, anorexia, vision problems,drug allergies, and tobacco oralcohol use.

A 22-year-old man presents to theemergency department with a2-week history of a worsening nonproductive,irritating dry cough andexertional dyspnea. The patient hasbeen otherwise healthy. He deniesfever, rigors, night sweats, hemoptysis,chest pain, palpitations, orthopnea,paroxysmal nocturnal dyspnea,ankle edema, and lymphadenopathy.

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Children sometimes have difficultyusing nasal sprays for allergies. Becauseof the anatomic configurationof the nasal passages and oropharynx,sprays are better directed whenthe head is tipped down, rather thanwhen held in the neutral or upwardposition.

A 76-year-old woman presents with chest pain-which she describes as“muscle tightness”- that began when she awoke in the morning. Thepain is constant, exacerbated by deep inspiration, and accompanied by asubjective sense of slight dyspnea; she rates its severity as 3 on a scale of1 to 10. She denies pain radiation, nausea, diaphoresis, palpitations, andlight-headedness. Her only cardiac risk factors are hypertension and a distanthistory of smoking.

To relieve an itch, have patients ruban ice cube over the affected areainstead of scratching with their fingernails.

Hold an otoscope with the light on in front of the patientand ask him or her to make believe it is a candle.

Reducing intraocularpressure (IOP)slows the progressionof glaucoma-or does it? Until recently,no evidence from arandomized controlled trialsupported the practice oftreating elevated IOP withdrug therapy or surgery.

A30-year-old man complains of chest pain, dyspnea, fever, and nonproductivecough that began earlier in the day. The pain is constant and does notdiminish with rest; it worsens somewhat with deep inspiration and has localizedto the left chest. The patient has had no nausea, vomiting, or abdominal pain.He has been immobile for several years secondary to spinal cord disease buthas no history of cardiopulmonary disease.

ROCHESTER, N.Y. -- Childhood obesity remained a focus of pediatrics during the year, along with concerns about safety, particularly the safety of psychiatric medications.

IOWA CITY, Iowa -- Children may be a bad influence on adults' diets, researchers here reported.

LA JOLLA, Calif. -- Aneuploidy can cause cancer or, in some circumstances, can keep it from happening, according to researchers here.

ROCKVILLE, Md. -- Meat and milk from the offspring of cloned cattle, pigs, and goats may soon find its way to American dinner tables, with the FDA's blessing.

BERN, Switzerland -- Six months after implantation of coronary stents, patients who received drug-eluting versions had 30% to 40% less collateral function than patients treated with bare metal devices, researchers here reported.

SAN DIEGO -- The editor-in-chief at the Journal of the American College of Cardiology confirmed today that an editorial on drug-eluting stents in the Jan. 2 issue contains a significant error.

PHILADELPHIA -- Proton pump inhibitors appear to be associated with an increase in hip fracture risk among older patients, particularly long-duration or high-dose use, according to a large study of British patients.