Educational objective: Mild to moderate cancer-related pain can usually be managed with nonopioid analgesics. However, if initial interventions are not effective, intermittent doses of short-acting opioids should be offered. If the pain requires frequent dosing or if bedtime dosing does not provide relief through the night, a long-acting opioid may be added.

A 34-year-old man comes to the physician after several days of difficulty walking. He also describes some "funny" sensations in his feet He has no recent skin rash, diarrhea, or joint pain. He has had lower back pain for the last week due to a lifting injury while he was moving. He visited friends in Connecticut 1 month ago and while there developed an upper respiratory infection that lasted 4 days. He smokes 1 pack of cigarettes a day and admits to occasional IV drug use. He has not been sexually active for 3 months. His temperature is 36. 7° C (98° F), blood pressure is 120/80 mm Hg, pulse is 90/min, and respirations are 16/min. Chest examination is unremarkable. The abdomen is soft and nontender. The liver span is 8 cm and the spleen is not palpable. Cranial nerves II-XII are intact Muscle strength is reduced in the lower extremities but well preserved in the upper extremities. Lower-extremity sensation is decreased. Mild hyperreflexia is noted bilaterally in the lower extremities . Stroking the soles of the feet elicits extension of the great toe.

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Educational objective: Spinal cord compression is characterized by signs and symptoms of upper motor neuron dysfunction distal to the site of compression. These include weakness, hyperreflexia, and an extensor plantar response. Cord compression is a medical emergency requiring prompt diagnosis by spinal MRI.

A 62-year-old man is brought to the emergency department due to left-sided weakness, numbness, and difficulty speaking. He was walking his dog about an hour ago and fell after developing sudden-onset weakness of his left upper and lower limbs. The patient did not lose consciousness. He has hypertension and type 2 diabetes mellitus but no other medical or surgical history. The patient's blood pressure is 170/96 mm Hg and pulse is 76/min and regular. On examination, his speech is dysarthric and he has left facial droop. The patient's left upper extremity muscle strength is 215 and left lower extremity strength is 3/5. Left hemisensory loss is present. His finger-stick blood glucose level is 190 mg/dl, and a noncontrast head CT scan reveals no abnormalities. Recent laboratory studies performed at the patient's primary care provider's office show his serum LDL is 152 mg/dl and hemoglobin A 1c is 7.6%.

Educational objective: Thrombolytic therapy (eg, intravenous alteplase) improves neurologic outcomes in patients with acute ischemic stroke when given within 4.5 hours of symptom onset. Before thrombolytics are administered, a noncontrast head CT should be performed to rule out hemorrhagic stroke, and the patient should be screened for other contraindications to therapy.

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A 76-year-old woman is brought to the office by her daughter due to progressively worsening memory and language difficulties. The patient first started having memory problems and word-findinq difficulties 5 years ago. She then began having difficulty balancing her checkbook and buying groceries. The patient became lost while driving to church last year and no longer drives. She is now dependent on her daughter for cooking and cleaning. Over the past 6 months, the patient's personality has changed from seeming apathetic to becoming more paranoid and agitated; she frequently claims to have seen her niece stealing from her purse. The patient recently developed urinary incontinence. She has a history of hyperlipidemia and osteoarthritis of the left hip and both knees. Blood pressure is 130/80 mm Hg and pulse is 90/min. Deep tendon reflexes are 2+ throughout, and she has preserved motor strength. The patient recalls none of 3 objects on memory testing and cannot draw a clock. Laboratory studies show normal electrolytes, lipid panel, TSH, vitamin 812, and complete blood count

Educational objective: Alzheimer disease, the most common type of dementia in the United States, is characterized by early and prominent memory impairment The differential includes dementia with Lewy bodies, frontotemporal dementia, and vascular dementia, as well as nondementing syndromes such as normal pressure hydrocephalus.

A 34-year-old man comes to the ·office for evaluation of hearing loss. The patient is a military pilot who has flown the past 8 years in noncombat zones. Regular hearing tests administered by the military have been normal until his most recent one. The patient has noticed no change in his hearing and has no ear pain, tinnitus, or vertigo. The results from the remainder of his annual physical, mental, vision, and cardiac tests were normal. The patient has no medical conditions and takes no medications. Aural examination shows clear, intact tympanic membranes bilaterally with no middle ear effusion. Review of the audiometry reveals a mild, bilateral, high-frequency hearing loss.

Educational objective: Chronic, excessive noise exposure can lead to sensorineural hearing loss due to the irreversible death of hair cells in the cochlea. Hearing screening programs are often mandated in high-risk occupations (eg, manufacturing, transportation).

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A 69-year-old man comes to the emergency department due to severe occipital headache, nausea, and vomiting for the last 3 hours. He has never had a headache like this before and has otherwise been in good physical condition. The patient was told several years ago that he has high blood pressure, but he has not been taking any medications or seen any health care providers. He has smoked half a pack of cigarettes daily for 40 years and drinks 1 or 2 cans of beer every evening. Both of his parents died of natural causes. Blood pressure is 160/90 mm Hg and pulse is 86/min and regular. His noncontrast head CT scan is shown in the image below.

Educational objective: Spontaneous cerebellar hemorrhage is typically caused by poorly controlled hypertension and presents with occipital headache, neck stiffness, nauseafvomiting, nystagmus, and ipsilateral hemiataxia. There is usually no hemiparesis or sensory loss. Early diagnosis with noncontrast head CT scan is important as emergency surgical decompression may be life-saving .