An 89-year-old hemiplegic man is seen for a routine physical examination. Major right brain stroke produced permanent dense left-sided motor deficit years ago. Has related vascular dementia.

A 28-year-old woman complains of intermittentright upper quadrant pain.The patient is thin, and she is not inacute distress.

Infection with hepatitis C virus (HCV) was recently diagnosedin a 45-year-old man when a positive enzyme-linked immunosorbentassay was followed by a polymerase chain reaction assaythat showed a viral load of 835,000 copies/mL. The patient probablyacquired the infection when he was using intravenous heroin, a practice he quit 10 yearsago. The patient is immune to both hepatitis A and hepatitis B viruses, and there is no coinfectionwith HIV. Liver biopsy shows moderate cellular inflammation (grade 3) and bridging fibrosis(stage 3) but no evidence of cirrhosis. Iron staining shows no abnormal iron deposition in theliver. The HCV genotype is 1A.

To help relieve the pain of a sorethroat, patients are often instructed togargle with warm salt water-usually4 times a day.

My patient, a 33-year-old man who works with his hands, presented with a growthunder his left thumb nail (Figure).

Two of my patients are older men (aged 62 years and 68years) who have benign prostatic hyperplasia; their prostatesare soft and nontender.

We read with great interest the “Dermclinic” case of a 44-year-old man with achanging pigmented lesion on his trunk (CONSULTANT, March 2001, page 354).

The authors of the Women’s HealthInitiative (WHI) study involving50,000 postmenopausal women concluded thata low-fat diet (goal: 20% of total calories) had no significant effect on the incidence of breast cancer, coloncancer, or heart disease. What should we be telling our patients?

A 3-day history of intermittent fainting spells brings a 49-year-old man to youroffice. His only significant medical history includes seasonal allergic rhinitis,for which he takes terfenadine, and mild depression, which is being treatedwith amitriptyline. A week ago, he began taking erythromycin, 500 mg qid,for acute pharyngitis.

A 41-year-old man is admitted for evaluation of acutechest pain, which started while he was watchingtelevision after dinner. The retrosternal pain was sudden,severe, pressing, and stabbing; it radiated to the neck andwas associated with dizziness and diaphoresis. The patientrated the pain as 9 on a scale of 1 to 10 (10 being the mostsevere). In the emergency department, he was given2 sublingual nitroglycerin tablets, which promptly relievedhis pain.

The pyoderma gangrenosum on theright anterior tibial area of a 40-yearoldman was thought to be associatedwith his rheumatoid arthritis. However,the cause of many of these ulcersis unknown. The patient could not recallany recent trauma. At least half ofall pyoderma gangrenosum lesionsoccur in persons who do not have associateddiseases.1

A tiny papule that arose after minortrauma to her finger marked theonset of this lesion, according to the48-year-old patient. She reports thatthe papule rapidly evolved into apustule that grew within 2 weeks intoa painful, undermined, purple-edgedulcer. The lesion did not respond toantibiotic therapy. The patient had rheumatoid arthritis.

A 57-year-old man was referred forevaluation of an enlarging, painful,irregular ulceration on his lower abdominalwall. The patient recalledhaving a small, red, “blister-like” lesionthat had rapidly expanded to itscurrent size of 2.5 * 4.5 cm. Hedenied specific injury to the skin;however, he often wore jeans thatrubbed the area. The patient wastaking ibuprofen for seropositiverheumatoid arthritis.

Delirium in older adults needs to berecognized early and managed as amedical emergency. Prompt detectionand treatment improve both shortandlong-term outcomes.1,2 Becausedelirium represents one of the nonspecificpresentations of illness in elderlypatients, the disorder can be easilyoverlooked or misdiagnosed. Misdiagnosismay occur in up to 80% of cases,but it is less likely with an interdisciplinaryapproach that includes inputfrom physicians, nurses, and familymembers.3

Q:What is the best screening test for suspectedrenal artery stenosis?

Although inhaled corticosteroids play a major role in the management of asthma, their effects on bone mineral density (BMD) are a concern for some patients. Fuhlbrigge and associates evaluated the cost-effectiveness of such therapy in light of the potential adverse effects on BMD. They found that inhaled corticosteroid therapy compares favorably with other standard medical interventions. However, the use of high doses over an extended period can affect overall costs and health.

A 66-year-old man presented with weight loss for 2 months, loss of appetite for several weeks, and abnormal chest radiographic findings. He denied chest pain, cough, fever, chills, shortness of breath, and chest trauma. He was an active smoker, with a 50-pack-year history of smok- ing, and a cocaine and alcohol abuser. His history included treatment of hypertension for 10 years and treatment of pulmonary tuberculosis 14 years previously.

Although most patients with frontal rhinosinusitis improve with medical therapy, those with persistent symptoms resulting from anatomic obstruction of the frontal sinus drainage pathways may be candidates for surgery. Over the past decade, traditional external approaches to the frontal sinus have been largely replaced by endoscopic procedures.1 These are performed with a small-diameter rigid endoscope that is passed through the nostril, avoiding the need for facial incisions. Instruments passed alongside the endoscope are used to remove obstructing tissue and drain the infected sinus.

Your elderly patients may not report a fall to you. Unless they are hospitalized for a severe injury, such as a hip fracture or subdural hematoma, many patients do not discuss falls. What constitutes an optimal strategy for evaluation and prevention of falls?