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HISTORY

Image 1An 88-year-old man who had left hip repair after a fracture a few months earlier is now admitted to behavioral hospital because of implacable refusal to take medications, and because of poor food intake and ongoing refusal of rehabilitation. Ambulated with a walker before fracture but now barely ventures out of wheelchair even with rolling walker and therapist guidance.

Has long-standing Alzheimer dementia, benign prostatic hyperplasia with urinary retention, and proven, newly reconfirmed chronic urethral catheter dependency despite α-blocker and 5α-reductase inhibitor; urinary tract infection recently treated without incident.

PHYSICAL EXAMINATION

Frail man sitting in a wheelchair. Severe bilateral wasting throughout the lower limbs comprising both cachexia [weight, 105 lb (47.5 kg)] and disuse atrophy. Left leg held in adducted position. Surgical scar well-healed. Muscle stretch reflexes symmetrical. Confused but socially gracious and altruistic. Not hostile or manipulative in talking about his weight and his lack of desire to eat, about which he communicates only that no foods here appeal to him.

WHAT’S YOUR DIAGNOSIS?

(answer on next page)
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