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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.

Which of the following is the most appropriate immediate next step in this patient's pain management?

A 71-year-old man comes to the ·office due to worsening low back pain. The patient is having significant pain with movement that is limiting his activity, as well as nocturnal pain that is disrupting his sleep. He has had no lower extremity weakness or numbness and no bladder or bowel dysfunction. He is taking ibuprofen 3-4 times a day, and it is not controlling his pain. The patient has a history of prostate cancer and takes leuprolide. He also received palliative radiotherapy for multiple lumbar spine metastases several months ago. Temperature is 37 C (98.6 F), blood pressure is 140/86 mm Hg, and pulse is 88/min. Lower extremity motor strength, deep tendon reflexes, and sensation are normal.

Educational objective: Chemotherapy-induced peripheral neuropathy typically presents as a symmetric, distal, sensory neuropathy that spreads in a stocking-glove pattern. Common causative agents include platinum-based medications (eg, cisplatin}, taxanes (eg, paclitaxel), and Vinca alkaloids (eg, vincristine }.

Which of the following is the most likely diagnosis?

A 58-year-old woman comes to the physician due to difficulty walking. Over the last several weeks she has also experienced bilateral foot numbness and tingling. She was diagnosed with advanced Hodgkin lymphoma 2 months ago and is currently undergoing chemotherapy containing bleomycin, doxorubicin, and vincristine. Her other medical problems include type 2 diabetes and hypertension. Physical examination shows bilateral weakness on dorsiflexion of the feet and loss of pain and temperature sensation affecting both toes. Knee jerk reflexes are 2+ bilaterally but ankle jerk reflexes are absent

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Educational objective: Bell palsy is a peripheral neuropathy of the facial nerve (cranial nerve VII) characterized by facial weakness that involves both the upper and lower face. It is thought to be caused by reactivation of neurotrophic viruses (eg, herpes simplex virus), resulting in inflammation, edema, and degeneration of the myelin sheath.

Which of the following is the most likely cause of this patient's current condition?

A 36-year-old woman comes to the emergency department due to left-sided facial droop. The patient woke up 4 hours ago and noticed that the left side of her face was sagging and that she was drooling from a corner of the mouth. She has had no facial numbness but has noticed an increased sensitivity to noise. The patient has a history of migraines, seasonal allergies, and gestational diabetes. Temperature is 36.5 C (97. 7 F), blood pressure is 120/70 mm Hg, and pulse is 78/min. BMI is 32 kg/m2. The face appears asymmetric with loss of the left nasolabial fold. When the patient is asked to smile, the left side of her face does not move. She is unable to raise her left eyebrow or completely close her left eye. Facial sensation to touch and pain is normal bilaterally. There are no skin or mucous membrane lesions.

Educational objective: REM sleep behavior disorder (RBD) is characterized by dream enactment during REM sleep atonia. Most patients with idiopathic RBD eventually develop a disorder of alpha-synuclein neurodegeneration, most commonly Parkinson disease.

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This patient is at greatest risk of developing which of the following disorders?