Social Sciences Main社會醫(yī)學(xué) 1-10課件

1、Social Sciences Main1-10Q 1A 68-year-old mart is brought to the hospital due to 2 days of progressive shortness of breath and cough. He has a history of severe chronic obstructive pulmonary disease and has had multiple recent exacerbations and several hospitalizations over the past year. During his

2、last hospitalization, he had acute respiratoryfailure requiring endotracheal intubation. This prompted the patient to make a living will specifying that he does not want any resuscitative measures or invasive therapies in the event of a life-threatening emergency. On examination, he is lethargic and

3、 arousabie only to noxious physical stimuli. His temperature is 37.2 (99)t blood pressure is 132/70 mm Hg， pulse is 102/min, and respirations are 32/min. Examination reveals diffusely decreased breath sounds, bilateral expiratory wheezes, and labored breathing. It is determined that he lacks decisio

4、n-making capacity. His daughter says,I have been taking care of my father for many years and I know him better than anyone. He would not want any aggressive measures. Please just make him comfortable. However, the patients wife demands that everything be done to save her husbands life, including int

5、ubation if necessary. She insists that she knows what her husband would have wanted and threatens to file a lawsuit. Which of the following interventions is the most appropriate next step?A.Consult the hospital ethics committeeB.Meet with all family members to achieve consensus on a course of action

6、 C. Obtain a court order to proceed with intubationD.Proceed with endotracheal intubation if medically indicatedE.Respect the patients living will and provide comfort care onlyA 1 Correct answer: EA living will (advanced directive) specifies a patients wishes for health care in advance of losing the

7、 ability to communicate or of becoming incapable of making his or her own decisions. In this case, the patient is incapacitated and his family members strongly disagree on the best course of action; both claim to have a better understanding of what the patient would have wanted in the current situat

8、ion. However, the physicians responsibility is to the patient, and ethically the physician must adhere to the patients wishes as outlined in the living will. The living will protects the patients autonomy and overrules the wishes of any family members.(Choices A, B, and C) Initiating a family meetin

9、g would be the first step if the family members disagreed about the course of action and there was no living will and/or no designated health care proxy in place. Referral to the hospital ethics committee or the courts for a judgment would become necessary if no consensus was achieved.(Choice D) Pro

10、ceeding with CPR or intubation would violate the patients wishes as expressed in his living will.Educational objective:A living will communicates the patients own wishes if he or she becomes incapacitated, and it overrules the wishes of the family.Q 2A 44-year-old psychology professor with a chronic

11、 history of rheumatoid arthritis presents for a follow-up examination. She is currently taking prednisone and infliximab, a regimen that has successfully stabilised her condition. Physical examination reveals no significant changes. Toward the end of the visit, she mentions that she would like to tr

12、y acupuncture as an adjunct treatment in addition to the medications she is currently taking. What is the most appropriate response to her request?A.Im sorry, but I am not very familiar with acupuncture and am reluctant to u combine the two therapies.B.I hope you are aware that acupuncture has its l

13、imitations.C.If you want to try acupuncture, 1 cannot continue serving as your physician. D.Why do you want to try acupuncture?E.How can an educated woman like you suggest something like this?A 2Correct answer: DAll patients enjoy the right to select treatment plans based on their personal values or

14、 preferences. When a patient expresses interest in alternative medicine, the physician should inquire about the reasons for departing from traditional treatments. It is important to determine if the patient is dissatisfied with the quality of her current care or if she is suffering from a bothersome

15、 side effect. Therefore, it would be most appropriate to ask this patient why she Is interested in acupuncture as an adjunct treatment.(Choice A) Because alternative medicine is enjoying increasing popularity, physicians have the obligation to become familiar with the most commonly used non-traditio

16、nal therapies, their side effects, and any potential drug interactions. In this instance, the physician must be prepared to discuss acupuncture and any contraindications or adverse effects were it to be added to her treatment regimen.(Choice B) The physician should encourage the patient to obtain re

17、levant literature and educational information about acupuncture from reliable sources. This should not be recommended in an attempt to instil! fear into the patient, but instead to enable the patient to make well-informed decisions. If the physician is already aware of potentially harmful interactio

18、ns, the patient should be told about them. The first step, however, Is to discover why the patient is interested in adding this alternative therapy to the treatment regimen.(Choice C) The physician should not abandon a patient who is interested in exploring an alternative treatment. Instead, the pat

19、ients preferences should be respected and the patient encouraged to learn more about the available options.(Choice E) Ridiculing the patient for an interest in alternative therapy will Inevitably undermine all future doctor-patient communication. Instead, physicians should encourage patients to keep

20、 them informed about any alternative treatments undertaken. Physicians should also seek to educate themselves about the more popular alternative medicines so that they can properly discuss potential side effects or drug interactions with patients.Educational Objective:When a patient is interested in

21、 alternative therapy, the physician should first inquire as towhy.A 3Correct answer:DBrain death is defined as irreversible loss of function of the whole brain; including the brainstem. There are several criteria for declaring brain death. Brain death is a legally acceptable definition of death, and

22、 artificial life support does not need to be continued, in this patients case, no further steps are legally required to remove him from the ventilator. Some states, such as New York and New Jersey, have regulations in place in case the declaration of legal death based on brain death is in violation

23、of an individuals religious beliefs.(Choices A and B) A court-appointed legal guardian Is sometimes needed when an individual (eg, senior citizen) does not have the capacity to make medical or life decisions and there is no healthcare proxy. Involvement of the hospital ethics committee is appropriat

24、e when the course of a patients care is unclear, particularly when a familys wishes are at odds with the goals of the healthcare providers. However, neither of these interventions is required in a patient with brain death.(Choice C) Patients In the hospital who die due to an unknown cause, a medical

25、 complication, suspected illegal activities, or within 24 hours of presentation must generally be reported to the coroner or medical examiner. This patient may need to be reported but not until after he has been disconnected from the ventilator.(Choice E) It is important to notify this patients fami

26、ly members of his condition and to discuss the removal of artificial life support. However, family permission is not legally required to discontinue mechanical ventilation in a patient with brain death.Educational objective:Brain death refers to a total loss of brain function and is a legally accept

27、able definition of death.Q 4A 60-year-old man comes to the physician complaining of weight loss and fatigue. A review of systems is positive for a change in bowel habits. Further evaluation shows the presence of colon carcinoma. The patient is told the diagnosis and Is educated about his treatment o

28、ptions and prognosis; he listens politely and does not ask any questions. He is a high school graduate and worked in a car factory until taking extended sick leave in recent weeks. The patient appears to comprehend the information without difficulty. He says he does not want treatment or interventio

29、n of any kind. The physician also serves as primary care physician for the patients wife. What would be the most appropriate next step in addressing this situation?A.Ask the patient why he does not want treatment or intervention of any kindB.Contact his wife and ask her to convince him to receive tr

30、eatmentC.Provide the patient with literature about the benefits of surgery and chemotherapyD.Respect the patients decision and do not schedule additional appointments E.Treat the patient against his wishes, obtaining a court order if necessaryQ 5A 32year-old woman comes to the physician with lower b

31、ack pain for the past week.She developed the pain after lifting some heavy furniture. She has no other symptoms. Physical examination shows mild paraspinal muscle tenderness. There is no radiation of pain with straight leg raise on either side, and no neurologic deficits are noted in the lower extre

32、mities. However, multiple bruises of various ages are noted on her abdomen, back, and chest. When the bruises are pointed out, the woman begins to cry. She is also quiet and avoids eye contact. Which of the following is the most appropriate initial response?A.Do you feel down, depressed, or hopeless

33、?B.Do you have a safety plan to leave the situation?C.I am going to call the police to come Investigate.D.Tell me more about the bruises on your body.E.These bruises are clearly from abuse and you do not deserve to be treated likethis.A 5Correct answer: DPhysicians should be alert to clues suggestin

34、g physical abuse as patients may not always report such incidents spontaneously. Multiple bruises, recurrent fractures, or repeated visits to the physician for unexplained injuries are all signs of possible abuse.In cases of possible abuse, the physician must be abie to conduct an effective patient

35、interview to provide proper care, ensure patient safety, and fulfill legal reporting requirements.The initial statement in such cases should be made tactfully and take into account the patients personality, emotional state, socioeconomic and cultural background, and the broader physician-patient rel

36、ationship. Open-ended questions and general statements of observation usually provide the best introduction to such a discussion and allow patientsto discuss the issues in their own words. Acknowledging the patients feelings and/or encouraging further dialogue about the bruises would be good startin

37、g points.(Choice A) Patients who are victims of abuse may have significant associated emotional symptoms, whether as a result of the abuse itself, from pre-existing affective illness, or from concurrent substance abuse. However, the physician should first gain an understanding of the abuse situation

38、 and then ensure immediate patient safety. Once immediate safety has been addressed, the physician and patient can discuss what steps may be taken to address concurrent affective symptoms.(Choice B) At some point in the conversation, the physician should discuss a safety plan with the patient. Howev

39、er, before making specific recommendations, it is necessary to understand the nature of the possible abuse and explore what options she may have already considered.(Choice C) Advising the patient to consider reporting the incident to the police may be appropriate in cases of suspected abuse, but thi

40、s is not a good opening statement. The prospect of filing charges may frighten the patient into denying the abuse and discourage a more thorough discussion of the issue.(Choice E) Although the physician may suspect abuse, it is important not to make unfounded assumptions. The possibility of abuse sh

41、ould be explored in an open and caring conversation with the patient. Value judgments, if any, should originate from the patient rather than the physician.Educational objective:Patients who are victims of suspected physical abuse should be approached with empathic interviewing techniques. The physic

42、ian should ask open-ended questions to allow patients to describe their situation on their own terms. The first priorities are to obtain an accurate and thorough understanding of the abuse and take any necessary action to ensure patient safety. Additional steps may then be needed to address concurre

43、nt emotional symptoms and satisfy legal reporting requirements.Q 6A 48-year-old woman is admitted to the oncology service for the 4th time in 2 months. She was diagnosed with breast cancer 2 years ago and has endured surgery, chemotherapy, and radiation. She also participated in multiple experimenta

44、l trials. Unfortunately, her disease has progressed. Today, the patient is hospitalized for hemoptysis and shortness of breath. She complains of severe pain in her back and has lost another 5 pounds since she was discharged 2 weeks ago. Her body mass index is 17 kg/m:.The patient has expressed a wis

45、h to stop ail treatment, go home, and enjoy her remaining days. She is found to have the capacity to make this decision. The oncologist, patient, and patients family decide that hospice care is the most appropriate plan. Which of the following is considered a requirement for referring a patient for

46、hospice care?A.Greater than 75% decline in ability to complete activities of daily livingB.Lack of family or other caregivers to assist the patientC.Patient has a do not resuscitate order . D.Patient has a prognosis of 6 monthsE.Patient has decision-making capacity F.Patient is actively dyingQ 7A 4t

47、h-year medical student working in the intensive care unit is helping to care for a 75-year-old man with end-stage lung cancer. The patient suffers a cardiac arrest and; despite Intensive resuscitation and emergency management, cannot recover and is declared dead 15 minutes later Team members provide

48、 emotional support to his family. The supervising physician reviews the details of the patients management with the student. The physician is aware of the students interest in critical care and asks if she would like to practice performing procedures, including pericardiocentesis and intubation, on

49、the deceased patient. Which of the following Is the most appropriate action by the student?A.Defer the procedures until a death certificate is completedB.Defer the procedures until an autopsy is performedC.Do not perform the procedures because they are unethicalD.Perform the procedures only if permi

50、ssion of the family is obtained E.Practice the procedures, but only under direct supervisionA 7Correct answer:DThe ethical dilemma of using newly deceased patients for training purposes involves weighing the conflicting considerations of respect for patient integrity with the need to train health ca

51、re providers to perform lifesaving procedures. The consensus of major medical organizations (eg, American Medical Association, American Heart Associations Emergency Cardiovascular Care Committee, Society for Academic Emergency Medicine) is that it is ethical for students to perform procedures for tr

52、aining purposes as long as the physician obtains permission from the family (or the patient prior to death) before the student performs the procedures. The training must occur as part of a structured training sequence and be performed under close supervision.If the patients previously expressed cons

53、ent is not documented and an appropriate family member cannot be found to grant permission, procedures for training purposes should not be performed. Physicians should also be aware that approaching a family for permission to perform procedures shortly after a death may be overwhelming and distressi

54、ng.(Choices A and B) It is not necessary for an autopsy or death certificate to be completed prior to performing a training procedure.(Choice C) Performing training procedures on newly deceased patients is considered ethical If the family (or the patient prior to death) has provided permission.(Choi

55、ce E) Performing any procedure requires permission of the family (or the patient prior to death), if permission Is obtained, the procedure should be performed under direct supervision.Educational objective:According to ethical guidelines, permission must be obtained from the family (or from the pati

56、ent prior to death) before procedures can be performed on a newly deceased patient for training purposes.A 8Correct answer:B Handling the aftermath of a mistake made by a colleague can be awkward, especially when the patients family is pressing for detailed information. Nevertheless, it is the actin

57、g physicians obligation to discuss the essential truth with the patient in a tactful and concise manner. The colleague is not available in this case. Therefore, a brief and honest explanation should be provided to the patient with the understanding that a definitive answer will be available once the

58、 matter has been fully discussed with the colleague. In the meantime, the patient has evidence of acute renal injury likely due to acute tubular necrosis (ATN), and appropriate therapy should be started to treat her acute condition.Physicians should consider admitting a mistake, especially under the

59、 following circumstances:Actual patient harmClear or potential clinical significanceAn unwanted treatment, device, or substance reaching the patient An unanticipated outcome An unexpected safety event(Choice A) For a physician to evade responsibility by saying he/she Is not the patients regular phys

60、ician is inappropriate. The acting physician is obligated to provide care that is In the patients best interest even if it could expose a mistake made by a colleague.(Choice C) Although it is true that intravenous hydration was not given prior to the procedure, it is important to get additional info