veryhot_post - Medical Board Vignettes - Science and Research Author Topic: Medical Board Vignettes  (Read 3097 times)

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Re: Medical Board Vignettes
« Reply #40 on: March 24, 2011, 12:44:11 PM »
Unilateral DNR Orders


If the physician has concluded that CPR would be physiologically futile, resuscitation  need not be offered as a treatment option. For example, if the patient is exsanguinated upon arrival to the ER and has been pulse-less with a flat electrocardiogram for 20 minutes, CPR may be withheld without surrogate consent. When the patient is terminal but not moribund, we recommend that consent include the following four mandatory provisions:

1) the physician must obtain a second opinion

2) the hospital ethics committee must be consulted

3) an atmosphere for negotiation between parties must be created

4) the patient's right to be transferred to another provider must be preserved
Easy way to borrow money online. Visit www.tala.ph

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Re: Medical Board Vignettes
« Reply #41 on: March 24, 2011, 12:56:06 PM »
Decisions to forgo interventions for children





With infants and children, as with adults, recommendations sometimes must be made about what forms of care are indicated when death is likely.
Although it often is psychologically and emotionally difficult to accept the death of an infant or child, physicians sometimes must recommend that certain interventions are not medically indicated because they are futile, providing no, or at best minimal, benefits. All of the cautions about the concept of futility  should be observed.


Case 1:

A fetus is delivered by spontaneous abortion at 21 weeks of gestation, weighing 350 g, and is hypoxic at birth.

Case II:

Jason, a 4 year ol boy , who was absent from his home for approximately 2 hours, is found at the bottom of a heated swimming pool. When drawn from the water, he is limp, has a grayish pallor and is cold. His father initiates mouth to mouth resuscitation, with no response. The Emergency Medical Services (EMS) arrives 8 minutes later. During the ambulance trip to the ER, CPR is given for 26 minutes and two doses of Epinephrine fail to stimulate any physiologic response. Rectal temperature is 35 degs C.



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Re: Medical Board Vignettes
« Reply #42 on: March 24, 2011, 01:02:45 PM »




Decisions to forgo interventions for children[/u]





With infants and children, as with adults, recommendations sometimes must be made about what forms of care are indicated when death is likely.
Although it often is psychologically and emotionally difficult to accept the death of an infant or child, physicians sometimes must recommend that certain interventions are not medically indicated because they are futile, providing no, or at best minimal, benefits. All of the cautions about the concept of futility  should be observed.


Case 1:

A fetus is delivered by spontaneous abortion at 21 weeks of gestation, weighing 350 g, and is hypoxic at birth.

Case II:

Jason, a 4 year ol boy , who was absent from his home for approximately 2 hours, is found at the bottom of a heated swimming pool. When drawn from the water, he is limp, has a grayish pallor and is cold. His father initiates mouth to mouth resuscitation, with no response. The Emergency Medical Services (EMS) arrives 8 minutes later. During the ambulance trip to the ER, CPR is given for 26 minutes and two doses of Epinephrine fail to stimulate any physiologic response. Rectal temperature is 35 degs C.




In case 1, no infant of that birth weight and gestational age is known to have survived under current medical regimens. Although this may constitute probablistic futility, it more likely reflects the physiological incapacity of immature lungs to perform their essential work and thus would constitute physiologic futility.

In case 2, resuscitative efforts can be discontinued on the grounds of probabilistic futility. Current data suggests that failure to obtain a physiologic response after more than 20 minutes of good resuscitative  efforts and two doses of epinephrine in the presence of normal body temperature justifies termination of intervention.

In the likelihood that Jason survives, Jason probably has sustained brain damage that would severely compromise his quality of life.

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Re: Medical Board Vignettes
« Reply #43 on: March 24, 2011, 03:25:02 PM »
this is so true. unfortunately, esp in the phils. if dli ipaundang sa family sa patient, dli sad paundangun sa doctor. i remember as an intern, we resuscitated a patient for two hours before declared dead. he had 24 epinephrines given na cguro with no response. kapoi intawn cge og pump.
"Live as if you were to die tomorrow. Learn as if you were to live forever." -Gandhi

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Re: Medical Board Vignettes
« Reply #44 on: March 24, 2011, 08:53:31 PM »

24 epinephrines ? Ka grabeh pood sa Pilipinas. Dili diay sila kahibalo that after 2 high doses of epi, mag saturate ang receptors sa pericardium?

By Medical Law, a brain that is deprived of oxygenated air for 5 minutes will be neurologically impaired. The situation that you personally had to endure was considered physiologically futile as well as fell in the realm of probabilistic futility. But it was noble, nonetheless.

One question, Dra, were you guys physically pumping the patient via manual cardiopulmonary resuscitation or where you guys using an defibrillator? In America, when dealing with patients who are suffering from acute Supraventricular Tachycardia, we usually give a dose (or two) of epinephrine and then cardioeversion to correct the abormal dysrythmia, which if left uncorrected for too long, becomes fatal.

Dra, I will nonetheless give you a standing ovation for that dedicated 2 hours of physical cardioeversion when all seemed lost. Daghan ko kaayo respect para nimo!!

:)



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Re: Medical Board Vignettes
« Reply #45 on: March 25, 2011, 07:32:49 AM »
Dra, I will nonetheless give you a standing ovation for that dedicated 2 hours of physical cardioeversion when all seemed lost. Daghan ko kaayo respect para nimo!![/i]

:)



we manually resuscitate especially at the ER and wards (and its not only me sad nagpump oi, puli puli mi sa mga co-interns) but i noticed we only used the defibrillator when the patient had insurance or good financial background (thats the sad part) and these are the family of patients who asks the doctors to not stop resuscitating... we usually alternate sa defibrillator then manual. with regards to the epi, thanks, new learning for me. Its not always all the time sad that we give more than 3 epis... most really is three epi's and we give 15mins for response if wla na, we appraise the family but like i said some family's in their verge of emotional insatbility cguro moask man ipadayun sa doc, especially if the patient is young so ambot nganu tagaan man sad epi nasad sa amo resident.

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Re: Medical Board Vignettes
« Reply #46 on: March 25, 2011, 09:42:31 AM »

i relayed your story today , dra, with members of my surgical group and we had a discussion about this. our lead surgeon, Dr. Bautisto, who is a product of UST (he is also head of the surgical wing here) gave all of us an interesting lesson: the difference between american and philippine hospital setting. the lecture gave all of us an eye opening awareness of the situation in the philippines. the story that he shared with us, bares similarity with that of your personal experience. and i appreciate them both.

it is saddening to hear that in the philippines, a defibrillator is held off if a patient shows no financial competence. So you mean to tell me that if a person from say Inabanga (suffering from chest pain that radiates to her back and jaw) is rushed to Ramiro Hospital and if she has no health insurance, in case she suffers an acute heart attack / or hypothetical SVT, she will not be given a defibrillator?

Here in the United States, even if one has no health insurance or not, if it is a medical Emergency, the patient must be given emergency care. Mao na ang differense sa setting.

Professionalism aside, I can sympathize with why you guys didn't give up, at the request of the patient's family. How old was the patient diay? And what was the cause of death? Hypertrophic cardiomyopathy or acute MI?

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Re: Medical Board Vignettes
« Reply #47 on: March 25, 2011, 10:05:38 AM »
A 69 year old man is hospitalized for an exacerbation of asthma. He is placed on albuterol and an inhaled corticosteroid , but due to low oxygen saturation, he is intubated. After 3 days in the hospital, he has a temperature of 39.4 degs C, a blood pressure of 104/ 63 mm Hg, a pulse of 108/ min, and a respiratory rate of 35/ min. On physical examination, the patient is found to have coarse rhonchi at the base of the lung fields bilaterally. The patient is producing purulent , foul-smelling sputum that shows Pseudomonas aeruginosa on culture analysis. Which of the following agents could be used to treat Pseudomonas aeruginosa infection?

A. Cefoperazone
B. Cefotaxime
C. Cefotetan
D. Ceftriaxone
E. Cefuroxime


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Re: Medical Board Vignettes
« Reply #48 on: March 26, 2011, 04:03:42 AM »
This was a hospital in Cebu. as in Ramiro however, I don't really know if they do use or not because I have never worked there but I know they make use of everything that they have. The patient's family just go home with a lot of bills to pay. In the setting in internship/clerkship cguro, hospitals like CDUH and the like make most of their many interns or PGI's in a code. Also the lasck of knowledge with the use of a defibrillator also comes to mind as well.

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Re: Medical Board Vignettes
« Reply #49 on: March 26, 2011, 04:25:02 AM »

4th generation cephalosporins has the highest bactericidal effect on Psuedomonas, but 3rd generation are also useful for serious gram neg infections, however, among the 3rd generation ceftazidime and cefoperazone are the ones most active against psedomonas aeroginosa so answer is A

A. Cefoperazone- 3rd gen

B. Cefotaxime-3rd gen
C. Cefotetan-2nd gen
D. Ceftriaxone- 3rd gen
E. Cefuroxime-2nd gen


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Re: Medical Board Vignettes
« Reply #50 on: March 26, 2011, 08:26:47 PM »
Excellent!!


;)

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Re: Medical Board Vignettes
« Reply #51 on: March 26, 2011, 08:28:44 PM »

This is good information , particularly the work setting information. Thank You very much for sharing this with me.


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Re: Medical Board Vignettes
« Reply #52 on: March 27, 2011, 03:01:04 AM »

patients less than 50-60 years old, usually of patients with MI.

Doc, keep those cases coming... and thank you.

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Re: Medical Board Vignettes
« Reply #53 on: March 27, 2011, 10:04:10 AM »
Way Sapayan, Doctora!  We have to motivate each other and help each other. :)

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Re: Medical Board Vignettes
« Reply #54 on: March 27, 2011, 10:06:21 AM »
A patient comes in to the ER complaining of chest pain and radiating pain to her back , left arm and jaw. You are the senior resident MD on the floor that night. You diagnose her as having Myocardial Infarct. As the resident MD, what is your treatment plan?


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Re: Medical Board Vignettes
« Reply #55 on: March 28, 2011, 12:18:18 PM »

additionally.

one of the reasons why cefoperazone is preferred is due to the fact that it does not cross the blood brain barrier and thus does not cause neural side effects.

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Re: Medical Board Vignettes
« Reply #56 on: March 28, 2011, 12:21:03 PM »

Treatment of Myocardial Infarction:

MONAB

M- Morphine
O- 100% oxygen
N- Nitrates
A-Aspirin
B-Beta Blocker

+

It is also good to give a patient tPA or Streptokinase (so long as he/she was not given this before, for allergenicity's sake)


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Re: Medical Board Vignettes
« Reply #57 on: March 28, 2011, 12:26:11 PM »
A 50 year old woman was diagnosed by her oncologist for a benign thyroid adenoma. She opted for surgical resection of the thyroid adenoma. After the surgery, the patient woke up and had a hoarse voice. This most likely was a result of a damage to which nerve during the surgical procedure?


A: Recurrent Laryngeal Nerve




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Re: Medical Board Vignettes
« Reply #58 on: March 28, 2011, 12:30:38 PM »
A 28 year old law student came to her family doctor's office complaining of vaginal iching. The patient reported to the doctor that the itching has been present for the past week now. Upon physical examination, the family doctor observes a milky gray colored exudate coming out of the patient's vagina and labial fold. Upon use of KOH, there is also an observable malodorous smell. After lab exams, you observe clue cells. What bacterial pathogen is responsible for this patient? And what is the name of the condition?


A: Gardnerella Vaginalis ; condition is known as: Bacterial Vaginosis

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Re: Medical Board Vignettes
« Reply #59 on: March 28, 2011, 12:34:57 PM »
A 3rd year Resident MD comes to your office complaining of excruciating pain when walking. Upon requesting him to walk , you observe an affected gait. He complains of pain on the lateral aspect of his ankle. Using your knowledge of Medical Anatomy, what ligament is most probably affected?


A: Talofibular Ligment; the reason why is because most common injured area in the foot is the lateral aspect, and the most common lateral ligament affected during an injury is the talofibular ligament.



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