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A 21-year-old man presents to the emergency department with abdominal painof 6 hours’ duration. When the pain began, it was diffuse and periumbilical; now,it is worse and localized to the right lower quadrant. It has been accompanied byanorexia but not by diarrhea or emesis. Lying down, consuming liquids, andshowering have not provided relief.

Q:How frequently does hypertension occur in association withobstructive sleep apnea (OSA), and how is OSA best treated?

Heart failure statistics are daunting:550,000 new cases each year, a 1-yearmortality rate of nearly 20%, and annualdirect and indirect costs that total $24.3billion.1 The diverse etiology of heartfailure and the complex, progressivecourse of the disease can make treatmentdecisions daunting as well.

Breast cancer causesmore deaths than anycancer except lung cancer inwomen of all ages. In womenbetween the ages of 40and 59 years, it is the leadingcause of cancer death.1

The US Preventive Services Task Force (USPSTF) recentlydetermined that there is insufficient evidence (Table) toeither recommend or discourage the use of vitamin supplementsto prevent cancer or cardiovascular disease.1 The useof supplements for other purposes was not included in theanalysis.

A 56-year-old African American woman complains of malaise, nausea, and vomitingof several weeks’ duration. In addition, urinary output is reduced, and shehas mild dyspnea. She denies abdominal pain, diarrhea, constipation, and bonepain; however, she has had a mild but persistent backache for several months.

Q:Recent research has defined mild cognitiveimpairment as a transitional state between thecognitive changes of normal aging and Alzheimerdisease (AD) and other dementing illnesses. Whatcriteria are used to differentiate mild cognitiveimpairment from more innocuous syndromes, such asbenign senescent forgetfulness? Are patients with mildcognitive impairment considered to have incipientclinical AD?

A 38-year-old woman presents with a pruritic, tender rash on the trunk and extremitiesthat has not changed over the past few days. She has taken fluvastatinand sertraline for 1 year and a popular, over-the-counter weight-loss product for1 or 2 weeks. The patient denies using any other medications. She has had norecent illnesses.

This recent headline succinctly summarizes a crisisof major proportions looming in the health carefield. According to the American Geriatrics Society,the fastest growing segment of the Americanpopulation consists of those who are 85 years andolder. Their numbers are expected to reach 19 million by2050. By 2020, more than 53 million Americans will be65 years or older. Many families will contain 2 generationsof geriatric patients.

Q:How can I best demonstrate to my patients who smoke theaccelerated decline in pulmonary function that occurs in smokersover time, in hopes of motivating them to quit smoking?

Tortuous, dilated varicosities; multiple smaller caliberabnormal perforating vessels; and chronic brawnyedema of chronic venous insufficiency (CVI) were seenon a 70-year-old man’s left leg (A). He reported that theedema and discoloration had worsened over the last15 years. The brawny edema stopped just above theankle, indicating that compression by the patient’s sockcontrolled the signs and symptoms of CVI.

For about 3 to 4 months, a 53-year-old man has had gradually worsening footdiscomfort. He describes the discomfort as a burning sensation accompaniedby numbness and tingling. Initially, these symptoms were present only in hisfeet, but for several weeks they have involved both ankles as well. Althoughthe discomfort is always present, it is occasionally aggravated by the bed coversor by heavy woollen socks. The patient has no skin lesions, motor symptoms,or other abnormalities of his legs or feet.

A 23-year-old man complains of looseness, clicking, and intermittent soreness in his right knee.In addition, the knee locks for short periods, and he has an occasional shooting pain up his rightthigh that causes the knee to buckle when he is walking. These symptoms have occurred intermittentlyover the past year, along with periods when the knee functions normally.

We have to let patientsknow that theimpact of mammography isnot that large-especiallyin women aged 40 to 49years. We simply do notknow whether early detectionof breast cancer leadsto improved outcomes inthis age group.

For 3 weeks, a 52-year-old woman has had right-sided, intermittent, dullabdominal pain and jaundice; these symptoms have worsened in the past fewdays. The pain radiates to the back, worsens with movement, is somewhatrelieved in certain positions, and is unrelated to eating or defecation. Duringthe past 3 weeks, she has also noticed darkening of her urine, a profound decreasein appetite, and an increase in fatigue; she has lost considerable weightbut is unsure of the exact amount. She has had no nausea, vomiting, or melenaor other change in her bowel movements.

The parents of a 3-year-old girl seekmedical evaluation of the nodules ontheir daughter’s back. The lesionshave been present since birth andhave grown with the child.

A 58-year-old man complains ofintermittent headaches that beganabout 2 months earlier and have recentlyincreased in severity. Theheadaches occur at various times ofthe day and improve slightly whenhe sits. He denies trauma, fever, photophobia,and other neurologicsymptoms. He has 1 alcoholic drinka day and has smoked 1 pack of cigarettesa day for the past 20 years.Medical history is noncontributory.

A 24-year-old African American man presents for a routine eye examination. Theocular findings are unremarkable; however, well-circumscribed areas of whitenedskin are noted on his forehead and hands (A and B). The patient reportsthat the patchy loss of pigment has been progressing over a number of years.