Social Sciences Main社會醫(yī)學(xué) 21-29課件

1、Social Sciences Main21-29Q 1A 32year-old woman at 42 weeks of gestation is admitted to the labor and delivery unit because of increased fetal movement and uterine contractions every 7 minutes. Her biood pressure is 120/60 mm Hg, pulse is 78/min: and respirations are 12/min. Fetal heart monitoring in

2、dicates that the fetus is in mild distress. An ultrasound confirms fetal macrosomia and findings suspicious for oligohydramnios. The patient is informed of the need for cesarean section. She is told that she is at significant risk of perineal laceration with vaginal delivery and that the fetus is at

3、 risk for asphyxia and death without an emergent cesarean section. However, she refuses to undergo cesarean section and insists on vaginal delivery. Further discussion reveals that she fully understands the risks of refusing the procedure, but insists on vagina! delivery. Which of the following is t

4、he most appropriate next step?A.Proceed with emergent cesarean section because there is evidence of fetal distressB.Proceed with emergent cesarean section because the fetus rights are more important than the patients autonomyC.Respect the patients decision, and proceed with vaginal deliveryD.Seek ou

5、t an alternative decision maker who will make better decisionsE. eek a court order forcing the mother to undergo emergent cesarean sectionA 1 Correct answer: CThis patient presents with post-term pregnancy, defined as a pregnancy that extends to or beyond 42 weeks gestation. Fetal risks from post-te

6、rm pregnancy include asphyxia, death, meconium aspiration, and intrauterine infection. Current recommendations advise emergent cesarean section if there are signs of fetal distress or oligohydramnios, as seen in this patient. Otherwise, expectant management with vaginal delivery is an option in sele

7、ct stable patients.In obstetrics, the medical decisions made by one patient (the mother) can directly affect the outcome of another (the fetus). In certain situations, such as this one, conflict can arise between the principles of maternal autonomy and the rights of the fetus as a person. Although t

8、he ethical code varies from country to country, In the United States, the mother is considered to have ultimate rights over her unborn child, assuming she has capacity. When a mother refuses a procedure or treatment that is in the best interest of the fetus, the physician should provide counseling a

9、nd education as to why the procedure is necessary. If the mother continues to refuse a procedure that would prevent irreversible harm to the fetus, the hospital ethics committee should be consulted, but the mother should not be coerced or otherwise forced into accepting any form of treatment she doe

10、s not want.Although this patients wishes are not In the best interest of her fetus, she has capacity and is entitled to make decisions that affect her unborn child. She cannot be forced into accepting an invasive cesarean section, even if her child might suffer harm. She should be advised of the ris

11、ks and likely consequences of vaginal delivery and the need for emergent cesarean section, but the physician must respect and comply with her final decision.(Choices A and B) Because this patient has capacity and her unborn child is still physically attached to her, she cannot be forced to undergo t

12、reatment for the benefit of her child; her autonomy supersedes the rights of the unborn child. Therefore, it is unlawful to proceed with the cesarean section against her wishes.(Choice D) Seeking out an alternate decision maker such as a spouse or a parent would be more appropriate in situations in

13、which the patient lacked capacity. However, as the patient currently has capacity and is making a decision with awareness of the risks and benefits, it is not appropriate to ask family members to make medical decisions for the patient. If the childs father Is involved, it would be appropriate to ask

14、 the patient to discuss her options with him prior to making this decision.(Choice E) Judicial intervention should only be considered as a last resort in exceptional circumstances, such as when the refused treatment poses insignificant risk to the mother, involves minimal Invasion of her bodily inte

15、grity, and would prevent substantial and irrevocable harm to the fetus. Although cesarean delivery would almost certainly benefit her unborn child, it is highly invasive and carries significant maternal risks.Educational objective:A pregnant woman who has capacity has the right to refuse treatment,

16、even if it places her unborn child at risk.Q 2A 28-year-old married woman who works with you in the clinic as a nurse privately comes to you because she missed a period this month. An over-the-counter urine pregnancy test confirms that she is pregnant. First-trimester laboratory testing reveals that

17、 she is also HIV positive. When you inform the patient of her HIV status, she is devastated. She hesitantly reveals that she had unprotected sexual intercourse with a former boyfriend several months ago. You explain that her husbands HIV status must be evaluated. The patient is horrified and says No

18、. I cannot tell him about this. He would never forgive me! Which of the following is the most appropriate first step?A.immediately inform the local health departmentB.Immediately Inform the local health department and the patients husbandC.Assure the patient that her condition will be kept absolutel

19、y confidentialD.Encourage the patient to tell her husband but tell her that you are required to inform the local health departmentE.Tell the patient that she cannot expect your medical or moral support if she does not tell her husbandA 2Correct answer: DThis patient presents with a HIV-positive test

20、 and wishes not to discuss her resuits with her husband. The Health Insurance Portability and Accountability Act allows patient information to be confidential, but reporting of diseases that are viewed as public health risks (e.g., HIV and tuberculosis) is required by public health departments. This

21、 patients HIV is potentially detrimental to the health and welfare of her husband and any other sexual partners she might have had in the past. Therefore, it is important that the individuals at risk also be notified. The health department (and not the physician) typically makes contact with all of

22、the patients sexual partners and informs them of being at risk for the disease, without giving any identifying information about the partner who placed them at risk.However, the most appropriate initial step is to encourage this patient to inform her husband of her diagnosis. Often, patients who hav

23、e just received devastating news need some time to absorb the impact before they feel prepared to inform their loved ones. If this patient persists in refusing to disclose her HIV status to her husband, she should be told that the physician is required to report the resuit to the local health depart

24、ment. They will eventually contact her husband about being at risk for HIV, without giving any Identifying information about the person who placed him at risk.(Choices A and B) Although informing the local health department will be necessary at some point, it should not be the first step. This patie

25、nt must be given an opportunity to inform her loved ones. The physician is required to notify the local health department within a certain time frame (48 hours In many states). The physician cannot notify the husband directly as this would violate HIPAA.(Choice C) Assuring this patient that her cond

26、ition will be kept absolutely confidential is inappropriate because her husband and any other sexual partners are at risk of contracting HIV and must be warned. Patient confidentiality is not an entitlement when the health of other individuals is at risk.(Choice E) Physicians have the responsibility

27、 to be empathetic and supportive in dealing with patients. This patient is no exception and deserves additional reassurance and encouragement while she struggles to accept her diagnosis. It is inappropriate to inform her that all support will be withdrawn unless she immediately tells her husband.Edu

28、cational objective:Patient confidentiality should not be maintained if it endangers the health and welfare of others. In cases of HIV, public health laws require reporting of the patients positive test results to the local health department. The health department usually contacts the patients contac

29、ts.A 3Correct answer:BWhen working with vulnerable patients such as children, it is imperative that physicians be alert to any signs of possible abuse. Abuse must be ruled out Jn any child with abrupt onset of mood changes; bedwetting, and/or academic difficulties. Other factors associated with Incr

30、eased risk of physical/sexual abuse in this child include unstable family situation, financial difficulties, and caregiver history of substance abuse.Physical/sexual and emotional abuse should be considered early when evaluating mood and behavioral symptoms in children due to the high risk of recurr

31、ent abuse and the need for prompt intervention. The physician could defer the physical examination due to the girls discomfort and instead ask if they could just talk, giving her a further opportunity to express any concerns. If abuse is confirmed or there remains a high index of suspicion of abuse,

32、 the physician is mandated to report it.(Choice A) Depression in children can present with behavioral changes, but there is not enough information to diagnose depression and initiate treatment in this child. The selective serotonin reuptake Inhibitor fluoxetine can be considered in preadolescent pat

33、ients for the treatment of major depressive disorder, along with psychotherapy.(Choice C) Urine toxicology screen can be considered for evaluating acute or sporadic behavior changes in adolescent patients. However, toxicology screening would likely be less helpful in preadolescent patients without o

34、ther risk factors for substance abuse or specific features of drug abuse.(Choice D) Changes in behavior and mood often occur in normal children in response to common psychosocial stressors such as divorce or parental discord. However, abuse must also be ruled out when a child presents with abrupt ch

35、anges 3n mood, bedwetting, and academic decline.(Choices E and G) Although initiating family therapy or referring the mother to a support group may be helpful, these would not take priority over assessing the patient for abuse.(Choice F) Cognitive-behavioral therapy has been studied for a number of

36、psychological disorders in children and adolescents. Although it may have a role in the long-term management of this patient, psychotherapy would be a secondary priority and should not delay the urgent need to exclude abuse.Educational objective:Physicians should have a high index of suspicion for p

37、hysical/sexual abuse in children with sudden behavioral problems, stressful family environments, or parents with active drug/alcohol abuse.Q 4A 16-year-old girl is brought to the physician for evaluation of moodiness. Her parents are concerned that she has been crying frequently since her boyfriend

38、ended their relationship last month. The girl has been going to her bedroom after school and refusing to speak to her parents about the breakup. She has no history of medical or psychiatric problems. Her father hunts for sport and keeps multiple rifles in the basement. Growth parameters and vital si

39、gns are normal. Examination shows a cooperative girl with fiat affect and lacerations on her wrist. Which of the following is the most effective method of preventing firearm injury in a patient with suicidal gestures?A.Remove all firearms from the homeB.Store loaded firearms in a locked containerC.S

40、tore unloaded firearms and ammunition in separate, locked containers D. Store unloaded firearms and ammunition in the parents bedroomE. Store unloaded firearms and ammunition in the same locked containerQ 5A 16-year-old girl is brought to the emergency department by her 13-year-old boyfriend due to

41、nausea, vomiting, and severe pain In her lower right quadrant. She also complains of some anorexia. The patient has had these symptoms for almost 12 hours. Her last menstrual period was 2 weeks agor and she has not been sexually active in the past 2 weeks. Her temperature is 33.1 C (100.6 F); blood

42、pressure is 110/70 mm Hg. pulse is 33/min: and respirations are 12/min. Examination shows diffuse discomfort In her abdomen that is increased in the right lower quadrant without guarding or rebound tenderness. Pregnancy test, workup for sexually transmitted diseases, and pelvic examination are negat

43、ive. Abdominal and pelvic computed tomography scans show nonspecific inflammation in the area of the appendix but are not definitive for appendicitis. The patients condition remains stable with improved pain control.However, it is recommended that she be admitted to the hospital for further observat

44、ion, with consideration for possible exploratory laparotomy in the next 24 hours if she worsens. This is discussed with the patient and her boyfriend. The physician inquires about obtaining consent for further medical care. The patient says that she lives with her parents but does not want them call

45、ed as they would find out Ive been spending time with my boyfriend, and they dont approve of him. Who is the appropriate person to sign the consent form for admission and further medical care?A.Parent of the adult boyfriend B.PatientC.Patients adult boyfriend D.Patients parentE.Physician in the emer

46、gency departmentA 5Correct answer: DThis patient is considered to be an unemancipated minor and her condition is stable (as opposed to an emergency). It is therefore necessary for a parent to provide consent.Minors in ail states may be given emergency care without consent if obtaining consent would

47、delay treatment, but the parents or legal guardians must be notified as soon as possible. Laws may vary by state regarding minors in some situations. Many states also allow minors to consent without parental notification for contraceptive services, sexually transmitted disease care, prenatal care, m

48、ental health services, and substance abuse. Minors who are parents may consent for treatment involving their own minor children.This patient may have the computed tomography scan without consent as it is part of the emergency care required to make a diagnosis and determine the need for surgery. Howe

49、ver, she does not need emergency surgery and will be admitted and observed, with the possibility of surgery in the future. Her parents or legal guardians should be notified and are required to give consent for further medical care.(Choices A and C) Although this girls boyfriend and his mother are ad

50、ults, they do not have the legal authority to provide consent for her medical care.(Choice B) Because this girl is an unemancipated minor, she does not have the authority to consent to medical treatment unless it is regarding a protected Issue such as contraception, pregnancy, or substance abuse.(Ch

51、oice E) Physicians do not have the legal authority to provide consent for an unemancipated minor.Educational objective:Unemancipated minors normally cannot consent to their own medical treatment. Parents or legal guardians must provide consent on the minors behalf before the physician can proceed, a

52、lthough there are exceptions in emergencies and other situations.Q 6A previously healthy 9-year-old boy is evaluated for a deep puncture wound to the foot. He was walking barefoot on the beach when he stepped on a rusty naiL His parents cleaned the wound with soap and water and applied pressure to i

53、t. The boy takes no medications. He has not received any vaccinations due to parental preference. The boys parents are divorced and have joint custody of him. The indications, benefits, and risks of tetanus vaccination are discussed with both parents. The mother consents to the proposed tetanus vacc

54、ination and requests that it be administered immediately.However, his father refuses to agree to the vaccination as he prefers to explore herbal remedies. Which of the following is the most appropriate next step in management of this patient?A.Ask the patient about his wishes and proceed with his de

55、cisionB.Consult the hospitals ethics committeeC.Obtain a court order to proceed with the proposed treatment D.Proceed with the proposed treatmentE.Withhold the proposed treatmentQ 7A 1-week-old girl is brought to the emergency department by ambulance for fever and irritability. She was bom at term b

56、y precipitous vaginal delivery and had an uncomplicated nursery course. Prenatal laboratory results were positive for group B streptococcal screen, for which the mother received intrapartum antibiotics. The Infants mother and father are both age 16. They are not married, and the father is not involv

57、ed in the infants care. The infant lives with her mother and maternal grandparents at the grandparents home; only the mother is present in the emergency department. The examination is concerning for meningitis, and the infant is intermittently apneic and hypoxic. The physician says that she will int

58、ubate the child, and the mother refuses. In this case, informed consent must be obtained from which of the following?A.Hospital ethics committeeB.Infants fatherC.Infants maternal grandparentsD.Infants motherE.Infants mother and maternal grandparents F.Informed consent is not requiredG.Legal counselA

59、 7Correct answer:FThe goal of informed consent is to provide patients with information that allows for educated decision making about their health care. The procedure and its indications, risks, benefits: and alternatives should be clearly described. Informed consent ideally is obtained from the par

60、ents of minors prior to performing a procedure. The exception is emergency conditions in which the parent or legal guardian is not available to provide consent and delaying evaluation would resuit in harm to the patient. Management of time-sensitive conditions: such as an unstable airway: should not