THE PROPER MANAGEMENT OF ABN

THE PROPER MANAGEMENT OF ABN. PAP SMEARS

Approach Based on Pap Smear

ASCUS = atypical squamous cells of undertermined significance.
AGCUS = atypical glandular cells of undetermined significance.
LSIL = low-grade squamous intraepithelial lesion (same as CIN I, or cervical intraepithelial neoplasia, grade 1).
Normal. Repeat every year from 18 to 65 years of age. If low risk, may change to every 3 years after 2 consecutive normals. After 65 years may discontinue after 2 consecutive normals.
No endocervical cells present. Pap test is considered inadequate and should be repeated.
ASCUS secondary to reactive/reparative changes or inflammatory changes. Look for causative agent on wet mount or cultures and treat. If no agent identified, treat with doxycycline 100 mg BID x 7 days. Repeat Pap test in 3 months. If resolved, repeat Pap in 6 months and then yearly. If abnormal at 3 months, do colposcopy.
ASCUS. Repeat Pap smear in 3 months and then every 6 months for 2 years reverting to yearly after having 3 consecutive normals. Colposcopy indicated if follow-up smear indicates ASCUS, or patient not able to comply with every 6 month follow-up exam.
LSIL or CIN I: Proceed to colposcopy.
ASCUS with dysplasia. Colposcopy indicated.
AGCUS. Colposcopy with endocervical curettage.
Other indications for colposcopy. Dysplasia (mild, moderate, severe), squamous cell carcinoma, adenocarcinoma, human papillomavirus infection (cervical or external genitalia), persistent inflammation.


Methods for Treating Cervical Dysplasia
Ectocervical.
Cryotherapy.
Laser therapy.
Topical 5-fluorouracil.
Local excision (biopsy forceps) if entire lesion well visualized.
Endocervical.
Surgical or laser conization.
Loop electrosurgical excision procedure.

unsatisfactory also if:
no endocervical cells present (= no transformation zone present)
no squamous metaplastic cells present (= no endocervical cells)

The new Bethesda System (11/2001) made some changes in reporting (I am not sure if USMLE already aware of this):
In the general categorization:
no more categorization as ASCUS/AGUS!!!
instead: negative for intraepithelial lesion or malignancy (this includes previous regenerative, infectious or repair changes)
or: Epithelial Cell Abnormality
see interpretation/diagnosis
(and then the pathologist will give you a categorization in the Descriptive Interpretation/Diagnoses as to squamous or glandular cell abnormality present or endometrial cells present in a woman>40 yoa etc. see below)
other changes mentioned in descriptive:

NON-NEOPLASTIC:
ORGANISMS:
trichomonas vaginalis
fungal organisms morphologically consistent with Candida spp
shift in vaginal flora suggestive of bacterial vaginosis
bacteria morphologically consistent with Actinomyces spp
cellular changes associated with Herpes simplex virus
OTHER NON-NEOPLASTIC FINDINGS:
Reactive cellular changes associated with
inflammation (includes repair)
radiation
intrauterine contraceptive device (IUD)
benign-appearing glandular cells status post hysterectomy
atrophy

OTHER:
endometrial cells in a woman>40 yoa

EPITHELIAL CELL ABNORMALITIES
SQUAMOUS CELL:
atypical squamous cells
- of undetermined significance (ASC-US)
- cannot exclude HSIL (ASC-H)

low-grade squamous intraepithelial lesion (LSIL)
- encompassing: HPV/mild dysplasia/CIN 1

high grade squamous intraepithelial lesion (HSIL)
- encompassing moderate and severe dysplasia, CIS/CIN 2 and 3
- with features suspicious for invasion (if invasion is suspected)

squamous cell carcinoma

GLANDULAR CELL:
atypical
- endocervical cells
- endometrial cells
- glandular cells

atypical glandular/endocervical cells, favor neoplastic

endocervical adenocarcinoma in situ

adenocarcinoma
- endocervical
- endometrial
- extaruterine
- not otherwise specified (NOS)

OTHER MALIGNANT NEOPLASMS: (specific diagnosis)
EDUCATIONAL NOTES AND RECOMMENDATIONS:

Stress testing in a COPD patient with Claudication

Understand the best method of stress testing in patients with obstructive lung disease and intermittent claudication.

Explanation:

The best stress test in general is exercise stress testing but patients with intermittent claudication cannot exercise adequately. In such patients a chemical stress test needs to be performed.

Dipyridamole stress is preferred over Dobutamine but in a case with obstructive lung disease Dipyridamole may produce bronchospasm whereas Dobutamine would not- therefore Dobutamine stress test would be the test of choice in a patient like this.

**A 55-year-old male with no significant past medical history presents to you because of pain and swelling in his right calf following a vigorous game of basketball. He denies any chest pain or shortness of breath. He smokes a pack of cigarettes per day and drinks socially. Physical exam is normal except for edema and tenderness of his right calf. Pulses are intact. A complete blood count, prothrombin time, and PTT are normal. Ultrasonography shows a deep venous thrombosis (DVT) involving the calf and popliteal veins on the right. An appropriate regimen of outpatient treatment for DVT would include:

A -Low molecular weight heparin 30 mg subcutaneously every 12 hrs plus warfarin 10 mg started immediately
B -Warfarin 15 mg started immediately
C -Low dose heparin (5000 units every 12 hrs subcutaneously) plus warfarin 15 mg stat
D -Low molecular weight heparin 60 mg subcutaneously every 12 hrs plus warfarin 5-10 mg started that evening
E -Aspirin 325 mg and warfarin 10 mg both administered immediately

Answer is D.  Low molecular weight heparin (Enoxaparin) has been repeatedly shown to be safe and effective for treatment of patients with DVT. Enoxaparin 1mg/kg every 12 hrs and Dalteparin 200U/kg daily have been used in clinical trials. Subcutaneous Heparin in prophylactic doses would be insufficient to prevent a recurrent thrombosis in this patient. Aspirin has not been shown to be effective in DVT.

**A 56-year-old man was seen 3 weeks after acute myocardial infarction. He is complaining of shortness of breath and exertion intolerance. He was found to become tachycardic on 30-foot walk (110 min) and his blood pressure in rest was 98/56 mmHg. The following ECG was obtained(shows st elevation in anterior leads). Which of the following diagnostic methods is the most suitable to establish a diagnosis in this patient?

A - Cardiac catheterization
B - Exercise stress test
C - Radionuclide ventriculography
D - Thallium stress test
E Echocardiography

Answer is E. ST segment elevation does not resolve completely during the acute phase of MI. This most commonly occurs with anterior infarcts. The features seen on this ECG are associated with the development of a ventricular aneurysm. Marked aneurysm dilatation may preclude effective systolic emptying of the left ventricle by expanding with the increase in intraventricular pressure during the systole. This leads to diminished stroke volume, cardiac output, pulmonary congestion, exercise intolerance, etc.
Confirmation of the diagnosis is most effectively made by echocardiography. Radionuclide ventriculography, Thallium imaging, and cardiac catheterization also have the ability to demonstrate aneurysms, but these methods are slower and more invasive; ventriculography and Thallium imaging may only be able to detect large abnormalities.

**A 34-year-old female was found to have a single 2 cm thyroid nodule. Which of the following is the method of choice to differentiate between malignant or benign disease?

A - Tc99m thyroid scan
B - Ultrasound examination of the nodule and surrounding thyroid tissue
C - MRI scan of the thyroid gland
D - Fine-needle aspiration biopsy
E - Excision biopsy of the nodule

The correct answer is D: Fine-needle aspiration biopsy
Educational objective: Review appropriate diagnostic procedures for thyroid nodule evaluation.
Fine-needle aspiration biopsy of a thyroid nodule has proved to be the best method for differentiation of benign from malignant thyroid disease. It is performed as an outpatient procedure and requires no preparation. A No. 25 - 1.5-inch needle is inserted into the nodule and moved in and out until a small amount of bloody material is seen in the hub of the needle. The needle is then removed, and the content of the needle is expressed onto the clean slide. A thin smear is prepared using another clean glass slide.
The slides are fixed and stained (Wrights, Geimsas or Papanicolaus stain). The sensitivity of the technique is about 95%, and specificity also about 95%. For best results this method requires adequate tissue sample and a trained cytologist to interpret it.

FNA biopsy can't identify well-diff Follicular CA.
You have asked about the best test, not the initial one.
Please clarify.

Thyroid fine needle aspiration (FNA) biopsy is the only non-surgical method which can differentiate malignant and benign nodules in most, but not all, cases. The needle is placed into the nodule several times and cells are aspirated into a syringe. The cells are placed on a microscope slide, stained, and examined by a pathologist. The nodule is then classified as nondiagnostic, benign, suspicious or malignant.

Nondiagnostic indicates that there are an insufficient number of thyroid cells in the aspirate and no diagnosis is possible. A nondiagnostic aspirate should be repeated, as a diagnostic aspirate will be obtained approximately 50 percent of the time when the aspirate is repeated. Overall, five to 10 percent of biopsies are nondiagnostic, and the patient should then undergo either an ultrasound or a thyroid scan for further evaluation.

Benign thyroid aspirations are the most common (as we would suspect since most nodules are benign) and consist of benign follicular epithelium with a variable amount of thyroid hormone protein (colloid).

Malignant thyroid aspirations can diagnose the following thyroid cancer types: papillary, follicular variant of papillary, medullary, anaplastic, thyroid lymphoma, and metastases to the thyroid. Follicular carcinoma and Hurthle cell carcinoma cannot be diagnosed by FNA biopsy. This is an important point. Since benign follicular adenomas cannot be differentiated from follicular cancer (~12% of all thyroid cancers) these patients often end up needing a formal surgical biopsy, which usually entails removal of the thyroid lobe which harbors the nodule.

Suspicious cytologies make up approximately 10 percent of FNA's. The thyroid cells on these aspirates are neither clearly benign nor malignant. Twenty five percent of suspicious lesions are found to be malignant when these patients undergo thyroid surgery. These are usually follicular or Hurthle cell cancers. Therefore, surgery is recommended for the treatment of thyroid nodules from which a suspicious aspiration has been obtained.

FNA is the first, and in the vast majority of cases, the only test required for the evaluation of a solitary thyroid nodule. (A TSH value should also be obtained to evaluate thyroid function.) Thyroid ultrasound and thyroid scans are usually not required for evaluation of a solitary thyroid nodule. FNA has reduced the cost for evaluation and treatment of thyroid nodules, and has improved yield of cancer found at thyroid surgery. Although a solitary thyroid nodule can enlarge or shrink over time, the natural history of solitary nodules reveals that most nodules change little with time.

**A 69-year-old female suffered cardiac arrest in the emergency room. After prolonged cardiopulmonary resuscitation, spontaneous heartbeat was achieved. However, she remained unresponsive. Seven days later she is still unresponsive, and it has been assessed that her condition is not reversible.

She had completed an advance directive about her health care several years ago. In this document she appointed her husband to have durable power of attorney for health care and specified that

she did not want her life to be maintained by artificial means for longer than 1 week. She also specified that she prefered to be allowed to die even if this meant cessation of nutritional support, ventilation, and hydration. However, her husband now requests that her care continue unchanged with full hydration, parenteral nutrition and ventilatory support.

Which of the following is the appropriate action to be taken?

A - Wishes of the husband should be followed since he has durable power of attorney for health care.
B - Ventilatory support, hydration, and nutritional support should be stopped at this point according to patients wishes.
C - Because of conflict, only the hospital ethical committee can make the decision.
D - Care for patient should be transferred to other physician who is willing to comply with patients wishes.
E - Current level of care should be maintained until court decision is obtained regarding further actions.

Answer is B. Patient in this question has executed durable power of attorney for health care. This power is delegated to her husband and his wishes should be followed as long as those wishes are not contrary to the wishes of the patient. Since this patient specified in her advance directive that she dose not want to be maintained beyond one week by means of ventilation, artificial nutrition and hydration, those measures should be stopped. Transferring patient to another physicians care does not change the situation in any way. Invoking the hospital's ethical committee may help the physician deal with the situation but should not change the outcome. There is no need for a court decision in this case since patient has explicitly stated her wishes in advance directive form.

**A 69-year-old man who is seen for routine yearly check-up, and who has no medical complaints, inquires about aspirin use. He was told by a friend who is a physician that everybody should take one aspirin a day so he started taking one 325 mg aspirin a day several weeks ago. He is not taking any other medications.

His physical examination is completely normal. His lipid panel is within normal limits as well as his electrolyte panel and complete blood count. His blood pressure is 127/67, temperature 36.8sC, weight 72 kg, and height 182 cm.

He asks what you recommend about aspirin use. Which of the following is the answer that is in accordance with available data at this time?


A - He should continue to take aspirin as he started since this therapy indeed leads to reduction in the incidence of cardiovascular incidents.
B - He should continue to take aspirin, but should take 81 mg a day since it has been shown that this dose has a much lower incidence of side effects.
C - He should stop taking aspirin because of the resulting high incidence of gastrointestinal bleeding in this age group.
D - He should continue to take aspirin until he is 80 years old, and than he should stop because there is no further benefit after this age.
E - He may continue to take aspirin, but should stop if symptoms of gastrointestinal distress occur or he notices blood in the stool (or melena). However, there is no data to prove benefit of this therapy in asymptomatic individuals.

Answer is E. Aspirin is effective in preventing stroke in those patients who have transitory ischemic attacks and also in prevention of nonfatal myocardial infarction and cardiovascular mortality in those with prior myocardial infarction and unstable angina. Some physicians believe that anybody should take daily aspirin as a means of prevention of cardiovascular morbidity and mortality, even those without any evidence of disease.
There are two trials that examined this issue. The U.S. trial was conducted on physicians and showed a significant decrease in fatal and nonfatal myocardial infarction, but not in total cardiovascular mortality. The other study was conducted in Great Britain and showed no difference (sample size was smaller than that of U.S. study). Both studies found somewhat increased incidence of stroke in those taking aspirin, but the difference was not statistically significant.
The U.S. Preventive Service Task Force does not recommend for or against aspirin use in primary prevention of myocardial infarction in asymptomatic men or women. Those with multiple risk factors but no signs or symptoms of cardiovascular disease should be counseled about benefits and risks of daily aspirin therapy (cerebral and gastrointestinal hemorrhage, gastrointestinal distress). Patients with existing coronary artery disease or transient ischemic attack or previous stroke are candidates for therapy if there are no contraindications.

**Eleven days after a massive stroke, patient does not have spontaneous respirations or response to any stimuli. Neurologic evaluation indicates that he is unlikely to regain consciousness. He has appointed his common law spouse to make the decisions about his health care by means of a living will in which he indicated that he does not want his life to be maintained using futile medical care. This was executed one and a half years ago while they lived in another state.

Patients spouse has requested that his hydration and nutritional support be withdrawn. The doctor treating the patient has strong moral convictions against terminating any kind of life support.

In this situation which of the following scenarios would be appropriate for the physician to follow?


A - He should continue to treat the patient according to his convictions since he is not obligated to practice medicine contrary to his moral beliefs.
B - He should comply with the requests of the patients spouse.
C - He can safely continue to treat patients as he wishes because the living will of the patient was executed in another state and it was done so more than 1 year ago, both of which make it invalid in the present situation.
D - He should transfer the care of the patient to another physician who is willing to comply with the wishes of the patients wife and his own expressed in the living will.
E - He cannot make this decision on his own and needs to consult the hospital ethics committee.

Answer is D. Educational objective: Emphasize the rights of physicians when confronted with morally unacceptable situations.
According to the Patient Self-determination Act, physicians are obligated to comply with REASONABLE requests of competent patients or their appointed agents (most commonly by the durable power of attorney for health care or by the living will). There is no time limit to the validity of such appointment, and advance directive executed in one state is valid in all others.
If, despite all other conditions being met, the physician still has moral disagreement with the decisions being made he is obligated to transfer the care of the patient to a physician who is ready to comply with those decisions.
A hospital ethics committee may be useful in providing a physician with counseling but it is not necessary in this situation.

**A 76-year-old man is hospitalized with stroke in the area of the right middle cerebral artery. He had a paroxysm of cough immediately after attempt to eat.
On physical examination he is alert and oriented to time, place, and person. He has severe dysarthria but no signs of aphasia. He has facial asymmetry due to left-sided facial droop, but his gag reflex is intact.

Which of the following is the most appropriate way to provide nutrition to this patient?

A - Placement of a percutaneous gastrostomy tube
B - Intravenous alimentation
C - Feeding through a nasogastric tube
D - Oral feeding supervised by a nurse and suctioning as needed
E - Clear liquid diet with advanced diet as soon as possible depending on patients clinical status

Answer is B. After a stroke about 25-45% of all patients develop dysphagia. The main problem that stems from dysphagia is aspiration pneumonia, which, if it develops, greatly complicates the clinical course and contributes to mortality. The patient in question had an attack of cough after an attempt to eat. This is a common sign of dysphagia. Physical examination of this patient revealed several findings that suggest dysphagia (facial nerve paresis and dysarthria). It is a common misconception that presence or absence of a gag reflex correlates with the risk of aspiration. This is not true. More important in the assessment of the aspiration risk are speech articulation, ability to swallow, and tongue movement. This patient has enough signs and symptoms to justify formal swallowing evaluation prior to beginning oral intake.
Many patients with dysphagia aspirate silently, without coughing or choking. Nurses supervision during the feeding may not ensure that successful suction will be possible if patient aspirates while eating.
Dysphagia after stroke commonly improves. Hence, a permanent form of enteral feeding, such as a gastrostomy tube, is not necessary.
Modification of the diet structure (giving clear liquid diet, etc.) may be a part of the dysphagia management in some circumstances, but liquids have the greatest potential for aspiration.
A nasogastric tube also may be used in certain circumstances, but it carries the risk of paranasal sinus infection as well as aspiration of regurgitated gastric content or leaked gastric content from a malpositioned tube.

**A 91-year-old male suffered a massive hemorrhagic stroke. He has been treated in the intensive care unit. He required intubation and ventilation. His heart rate has been irregular; blood pressure dropped during the first 12 hours of treatment to less than 80 systolic. Blood pressure has been maintained for the last 6 hours with a maximal dose of the dopamine.

His two sons arrived in the hospital from the other part of the country. Both are very distressed. They have not seen their father for more than 4 years and plans were being made to have a family reunion in a couple of months. Patients wife of the last 2 years is also in the hospital. She holds a durable power of attorney for health care for the patient and states that his wish would be to stop these aggressive measures of life support.

Patients sons strongly disagree and wish to continue life support as long as possible. Which of the following is appropriate action to be undertaken?

**A - Since there is disagreement about future care and patient cannot express his wishes, it is necessary to organize an extended family conference and try to reach consensus on future care.
B - The wishes of the sons should be followed because they may sue the hospital if care is stopped.
C - The wishes of the sons should be followed because stopping the care equals euthanasia.
D - The wifes instructions should be followed since she holds a power of attorney for the health care of this patient.
E - Life support should be continued until brain death can be established, at which point care should be stopped because this avoids any legal issues in the case

Answer is D. A durable power of attorney for health care which takes written form is authorized by statute in practically every state. It enables a decisional person to appoint someone else (the agent) to make future medical treatment choices for him or her in the event of decisional incapacity. The agent may or may not be a family member. A durable power of attorney, unlike a living will, supplies an actual person who is available when decisions must be made and who is authorized to advocate for and interpret the expressed and inferred whishes of the patient. The availability of such an agent is advantageous both to the patient who needs advocacy and the physician who is trying to act according to the wishes of the incapacitated patient.
In this case the patients wife acts as the patients agent, and her instructions take precedence over all other wishes of the family members.

**A patient with cytomegalovirus retinitis has been treated with intravenous ganciclovir for the last 4 months. On the most recent laboratory findings a sudden drop in the thrombocyte count was noted (20,000 mm3). Which of the following is the most appropriate action in this situation?

A - Discontinuation of the therapy
B - Exchange of ganciclovir with intravenous foscarnet
C - Exchange of ganciclovir with acyclovir
D - Exchange of ganciclovir with valcyclovir
E - Continuation of ganciclovir therapy

Answer is B. The major drugs that are used for treatment of cytomegalovirus retinitis are intravenous ganciclovir and foscarnet, oral ganciclovir, intraocular ganciclovir, and intravenous cidofovir. Ganciclovir and foscarnet have equivalent efficacy against the retinitis. Major side effects of the ganciclovir are neutropenia and thrombocytopenia (limiting use in up to 16% of patients). Ganciclovir should not be given with absolute neutropenia of less than 500 mm3 and thrombocytopenia 25, 000 mm3.
Foscarnet increases serum creatinine concentration (due to acute tubular necrosis) and may produce symptoms of hypocalcemia during drug infusion because of chelation of serum ionized calcium (and magnesium). These side effects have been dose-limiting in up to 20% of patients.

**A 53-year-old male smoker presented with a 2-week history of expectorating sputum streaked with a blood. He denies any fever or chills or increases in the intensity of his cough. Physical examination and chest X-ray are unremarkable. Which of the following is an appropriate next step in the diagnostic work-up of this patient?

A - Fiberoptic bronchoscopy
B - MRI of the chest
C - High resolution CT of the chest
D - A and B
E - A and C

Answer is E. Fiberoptic bronchoscopy and high resolution CT (HRCT) are, in many ways, complementary to each other. Both of those procedures have advantages in certain clinical situations. In one study HRCT demonstrated all tumors seen on bronchoscopy as well as several which were beyond bronchoscopic range. On the other hand, HRCT could not detect bronchitis or subtle mucosal abnormalities that could be seen on bronchoscopy. In one study HRCT was particularly useful in diagnosing bronchiectasis and aspergillomas, while bronchoscopy was diagnostic of bronchitis and mucosal lesions such as Kaposis sarcoma. The patient in question is at high risk for pulmonary carcinoma; as of today, the procedures are considered complementary in this setting.

**A 42-year-old female presented with pain in the left leg. Pain was mild, dull but constant. On examination there was a difference in the circumference of the calves, with the left leg being 2.5 cm (1.0 inch) bigger. There was also a 1.5 cm increased circumference in the left thigh area. Palpation of the left calf revealed tenderness on palpation in popliteal fossa and half way down the posterior aspect of the calf. This was the first such episode in her life. Her past medical history was significant only for multiple (3) spontaneous abortions. Impedance pletismography confirmed deep venous thrombosis. Which of the following findings is most likely in the laboratory results of this patient?

A - Polycytemia
B - Thrombocytopenia
C - Low white blood cell count
D - Hyponatremia
E Hyperkalemia

Answer is B. This patient presents with confirmed deep venous thrombosis and remarkable history of the spontaneous abortions. This constellation of symptoms and signs is highly suggestive of antiphospholipid antibody syndrome (antibodies directed against either phospholipids or plasma proteins bound to anionic phospholipids. Most common symptoms are venous and arterial thrombosis, recurrent fetal losses, and thrombocytopenia. Other possible findings include livedo reticularis, migraine headaches, Raynauds disease, hemolytic anemia, neurologic dysfunction, renal disease, pulmonary hypertension, avascular necrosis, and adrenal insufficiency.
In rare cases, primary antiphospholipid syndrome may result in multiorgan failure because of multiple vessel occlusions.

**A 55-year-old man comes to your office for evaluation of abnormal hemoglobin of 17.8 g/dl and dyspnea. Three years ago he underwent uvuloplasty because of snoring and had complete relief of his symptoms. He quit smoking 5 years ago and is a social drinker.

On physical exam he is 175 centimeters tall, weighs 70 kg and his blood pressure is 124/86 mm/Hg. Examination of the abdomen reveals an enlarged spleen.

Laboratory studies are as follows:

Hb - 17.8 g/dl, MCV 85 fL
WBC 13, 000 microliter
Platelet count 500, 000
O2 saturation - 96%
PH - 7.42, PCO2 - 40, PO2 - 88
Venous blood P50 - 27 mm/Hg
Erythropoietin - 2 mU/ml
RBC mass - Increased

What is the most likely diagnosis?

A - Sleep apnea
B - Renal cell carcinoma
C - COPD
D - Hemoglobinopathy
E - Polycythemia rubra vera

E

Criteria for diagnosing polycythemia rubra vera include:
Category A - increased red blood cell (RBC) mass,
splenomegaly and normal oxygen saturation.
Category B - platelet count more than
400,000/microliter, white blood cell count (WBC)
more than 12,000 /microliter, leukocyte alkaline
phosphatase score more than 100. Serum level of
vitamin B12 more than 900 ng/L.
The presence of all three criteria in category A establishes the diagnosis. If the patient has increased RBC mass with either of the other two category A criteria, then 2 of the 4 category B criteria are necessary to establish the diagnosis.
Erythropoietin levels are elevated in patients with secondary polycytemia seen in the other conditions listed

*******Will somebody answer the CCS presented below..Thanks*******
1. Myocardial infarction
2. Hypothyroidism
3. Renal cell mass, most likely Renal cell carcinoma
4. Acute pulmonary edema
5. Diabetes mellitus type 2
6. Neonatal hyperbilirubinemia secondary to cephalohematoma reabsorption
7. Opioid overdose
8. Major depression
9. Ovarian torsion

***A 16-year-old female presents to a family physician to obtain a referral for family therapy. She is estranged from her mother and stepfather, who see the same physician. For many years, this patient responsibly cared for her four younger siblings while their single mother worked. Since her mother's marriage, the family has become involved in a fundamentalist church. The patient moved out when she felt the social and moral restrictions of the family's religion were too burdensome for her. The patient seemed quite mature; she maintained a 3.5 GPA, along with a part-time job. She demonstrated a genuine desire for reconciliation, and the therapy referral was provided.
She also requested and obtained a prescription for contraceptives during the visit, with the assurance that her sexual activity would be kept confidential. In follow-up, she reported that the therapist had informed her that if she mentioned anything about being sexually active with her adult partner, he would be obliged to report her to the state. The patient was very concerned about the conflict between this statement and the family physician's prior assurance of confidentiality.

Should this patient's confidentiality be broken?

No

While the physician has a moral obligation to obey the law, he must balance this against his responsibility to the patient. In researching the Criminal Code of Washington, the physician learned that sexual intercourse with a minor, at least 16, but under 18, is a class C felony, and a reportable offense, if the offender is at least 90 months older than the victim. This patient's relationship did not actually meet the criteria for mandatory reporting. Had this not been the case however, the physician could be justified in weighing the balance of harms arising from the filing of such a report.
There is little justification for informing the family of the young woman's sexual activity. Due to the family's strong fundamentalist beliefs, significant damage would have occurred in the family reconciliation process with this discovery. Although they would clearly disapprove of the patient's actions, her choices carry no risk of harm to them.
Criteria for diagnosing polycythemia rubra vera include

**Your patient with cryptococcal meningitis eventually agrees to be tested for HIV and her test comes back positive. Due to her opportunistic infection she receives the diagnosis of AIDS.
Should she be reported to the department of public health?

Yes

AIDS is a currently a reportable diagnosis in all 50 states of the union. Her diagnosis should be reported to the department of public health. Notably, HIV positivity without the diagnosis of AIDS is not reportable in all states. Currently, 30 of 50 states requires reporting of a positive test. It is important to find out the local states laws where you are practicing to know how to approach this problem.

**A 22-year-old woman is admitted to the hospital with a headache, stiff neck and photophobia but an intact mental status. Lab test reveal cryptococcal meningitis, an infection commonly associated with HIV infection. When given the diagnosis, she adamantly refuses to be tested for HIV.
Should she be tested anyway by the medical staff?

No

Testing for HIV, as for any other medical procedure should be done only with the informed consent of the patient. Testing without consent is unethical in this setting. The physician's role in the care of this patient is ongoing support, education and guidance about her various options for care.

**A 55-year-old man has a 3-month history of chest pain and fainting spells. You feel his symptoms merit cardiac catheterization. You explain the risks and potential benefits to him, and include your assessment of his likely prognosis without the intervention. He is able to demonstrate that he understands all of this, but refuses the intervention.
Can he do that, legally? Should you leave it at that?

Yes

This patient understands what is at stake with his treatment refusal. As he is competent to make this decision, you have a duty to respect his choice. However, you should also be sure to explore his reasons for refusing treatment and continue to discuss your recommendations. A treatment refusal should be honored, but it should also not be treated as the end of a discussion.

**A 64-year-old woman with MS is hospitalized. The team feels she may need to be placed on a feeding tube soon to assure adequate nourishment. They ask the patient about this in the morning and she agrees. However, in the evening (before the tube has been placed), the patient becomes disoriented and seems confused about her decision to have the feeding tube placed. She tells the team she doesn't want it in. They revisit the question in the morning, when the patient is again lucid. Unable to recall her state of mind from the previous evening, the patient again agrees to the procedure.
Is this patient competent to decide? Which preference should be honored?

This patient's underlying disease is impairing her decision making capacity. If her wishes are consistent during her lucid periods, this choice may be considered her real preference and followed accordingly. However, as her decision making capacity is questionable, getting a surrogate decision maker involved can help determine what her real wishes are This patient's underlying disease is impairing her decision making capacity. If her wishes are consistent during her lucid periods, this choice may be considered her real preference and followed accordingly. However, as her decision making capacity is questionable, getting a surrogate decision maker involved can help determine what her real wishes are

**A 3-year-old child is brought to your clinic with a fever and stiff neck. You are quite certain the child has meningitis. When you discuss the need for a spinal tap and antibiotic treatment, the parents refuse permission, saying, ' We'd prefer to take him home and have our minister pray over him.'
Can the parents refuse treatment in this case? How should you handle this?

The physician has a duty to provide treatment to a child when denying that treatment would pose a significant risk of substantial harm. Failure to diagnose and treat bacterial meningitis would seriously threaten the health and even life of this child. The physician should share his view with the family and seek to elicit their cooperation through respectful discussion. Inviting their religious leader to the hospital while also providing standard medical therapy may prove to be an acceptable compromise. Should these efforts not result in parental permission, the physician is justified in seeking legal help so as to proceed with the procedure and treatment of the child. In most states a physician is legally authorized to provide emergency treatment to a child without a court order when delay would likely result in harm.

**A mother brings her 18-month-old daughter to your office for a routine physical examination. The child has had no immunizations. Her mother says that they believe in naturopathic medicine and prefer not to immunize their children.
What is your role in this situation? Can parents refuse to immunize their children?

Yes

The risk faced by unimmunized individuals is relatively low, and the mother's refusal to immunize does not pose a significant likelihood of harm to her child. The physician should be sure that the child's mother understands the risks of remaining unimmunized and attempt to correct any misconceptions about the degree of risk associated with getting immunized. If the mother persists in her request, the physician should respect her wishes.

Can parents refuse to provide their children with necessary medical treatment on the basis of their beliefs?

Parents have legal and moral authority to make health care decisions for their children, as long as those decisions do not pose a serious threat to the child's physical well-being. Parents should not be permitted to deny their children medical care when that medical care is likely to prevent substantial harm or suffering. If necessary, the physician may need to pursue a court order in order to provide treatment against the wishes of the parents. Nevertheless, the physician must always take care to show respect for the family's beliefs and a willingness to discuss reasonable alternatives with the family.

What kinds of treatment can parents choose not to provide to their children?
Parents have the right to refuse medical treatments when doing so does not place the child at significant risk of substantial harm or suffering. For example, parents have the right to refuse immunizations for their children on religious or cultural grounds.

Ref. ETHICS IN MEDICINE University of Washington School of Medicine

**A 13-year-old white male complains of a 2-month history of pain in the anterior aspect of the right knee and mild intermittent swelling of the knee. Although he plays soccer and runs track, he cannot recall any singular traumatic event. He has noticed that the pain is worse after running or going up or down stairs. He has not noticed any locking, clicking, or giving way. Physical examination shows mild thickening of the patellar tendon and tenderness at the insertion of the patellar tendon. There is no effusion or instability.

Which one of the following is true regarding this patient's condition?

a. Radiographic findings of a fragmented epiphysis are characteristic
b. A CBC and sedimentation rate should be obtained to rule out inflammatory disorders
c. The problem is usually self-limited and generally responds to a brief period of activity restriction
d. The problem is caused by avascular necrosis of the tibial tubercle

e. A bone scan is indicated at this point to confirm the diagnosis and rule out inflammatory and neoplastic conditions

C

Osgood-Schlatter disease is a generally self-limited condition characterized by tenderness and swelling of the patellar tendon and by excessive enlargement of the proximal tibial tubercle. It is a disease of pre-adolescence, commonly seen between the ages of 11 and 15 in boys and 8 and 13 in girls. It is more common in boys. There is usually a history of participation in sports and a recent growth spurt, and the problem is unilateral in three-fourths of patients. It is caused by a contracted quadriceps mechanism producing traumatic stress on the proximal tibial tuberosity during the growth period, when the tibial tubercle is susceptible to strain. There is no avascular necrosis. The pain is usually worse after activities that stress the patellofemoral unit, such as running or climbing stairs. It is a clinical diagnosis, and requires no confirmatory testing in the usual mild to moderate cases. Roentgenographic findings are variable and are not required to make the diagnosis. It usually responds to activity restrictions, although severe cases may require a temporary period of cast immobilization.

**A 2-year-old Hispanic female visiting from Mexico presents with a 1-week history of repeated episodes of severe coughing. Her mother reports that a runny nose and 'cold' preceded the onset of the cough. The mother notes that the family with whom they are staying has a dog who recently contracted 'kennel cough.' The child is currently afebrile and appears mildly ill; her lungs are clear. When coughing, she is clearly uncomfortable and vomits a small amount of mucus.
Your management would include which one of the following?

a. Administration of immune serum globulin intramuscularly
b. Having the dog treated by a veterinarian to avoid spread of this infection to other persons in the home
c. Oral erythromycin therapy for 2 weeks
d. Reassurance that the cough will abate over the next week
e. Hospitalization for ribavirin (Virazole) aerosol therapy

C

This child's presentation is highly suspicious for pertussis, given the severe coughing paroxysms and possibility of inadequate immunization. Two weeks of oral erythromycin is recommended for mildly to moderately ill children, principally to halt the spread of the illness. Ribavirin is used for respiratory syncytial virus infection, generally seen in much younger children and with more respiratory distress. The cough of pertussis often lasts several weeks. Although 'kennel cough' is produced by a canine Bordetella species, B. pertussis is seen only in humans. Immune globulin is not recommended

HIV patient does not want to tell wife - Can you?

Yes. There is a risk to somebody,s life in this case. The human benefit of breaching confidentiality in this case is much more than not breaching it. Even if the patient says that he will tell his wife, you must confirm that this is done. If he does not do it, you must ensure that she is informed (even if this involves the health department/police contacting her if you cannot manage so yourself).

This comes from the fact that confidentiality need not be maintained if there is danger to somebody's life.

The following information is posted from the NY state regulations of reporting to partners:

'Notifying Partners:

If you test HIV positive, your provider will talk with you about the importance and benefits of notifying your partners of their possible exposure to HIV. It is important that your partners know they may have been exposed to HIV so they can find out whether they are infected and benefit from early diagnosis and treatment. Your provider may ask you to provide the names of your partners, and whether it is safe for you if they are notified. If you have been in an abusive relationship with one of these partners, it is important to share information with your provider.

For information regarding services related to domestic violence, call 1-800-942-6906.

Under state law, your provider is required to report to the health department the names of any of your partners (present and past sexual partners, including spouses, and needle sharing partners) whom they know.

If you have additional partners whom your provider does not know, you may give their names to your provider so they can be notified.

Several options are available to assist you and your provider in notifying partners. If you or your provider do not have a plan to notify your partners, the health department may notify them without revealing your identity. If this notification presents a risk of harm to you, the Health Department may defer the notification for a period of time sufficient to allow you to access domestic violence prevention services.

If you do not name any partners to your provider or if a need exists to confirm information about your partners, the health department may contact you to request your cooperation in this process.

Because the patient's wife is at serious risk for being infected with HIV, you have a duty to ensure thatshe knows of the risk. While public health law requires reporting both your patient and any known sexual partners to local health officers, it is generally advisable to encourage the patient to share this information with his wife on his own, giving him a bit more time if necessary.

In earlier days, when doctors would see a patient in whom the prognosis was poor, they may have ordered 'slow code'. It used to mean that give a half hearted attempt of resuscitation to document it on the chart.

I have heard of it during training from some old-timers but never should this be an option. Nowadays if the attending decides that the intervention (CPR) will be futile, the attending has the right to decide that NO code should be performed. Even though , technically it is the right answer for the exam, rarely does one see that as a unilateral decision as the attending discusses and convinces the family before doing this.

Minor wanting contraception (this is excerpted from the article on adolescent confidentiality):

If an adolescent asks you for contraceptives - you should not only give /prescribe them but you as a good physician must take extra time to explain their use and side effects as some adolescents have no idea about these devices/pills and their limitations. It is wrong to call the parent in to tell them about these issues or tell the police about something the adolescent vested in you or to deny this young individual care that an adult would get routinely from you.

Only abuse, suicide or homicide cannot be granted confidentiality.

As to which method to use for contraception, one must stress the importance of barrier methods (condoms) in prevention of STDs which is not provided by Oral contraceptive pills. Safer still would be to use BOTH together.