Minors and the Right to Consent to Health Care

Minors and the Right to Consent to Health Care

The notion that many minors have the capacity and, indeed, the right to make important decisions about health care has been well established in federal and state policy. Many states specifically authorize minors to consent to contraceptive services, testing and treatment for HIV and other sexually transmitted diseases, prenatal care and delivery services, treatment for alcohol and drug abuse, and outpatient mental health care. With the exception of abortion, lawmakers have generally resisted attempts to impose a parental consent or notification requirement on minors' access to reproductive health care and other sensitive services. Nevertheless, the movement to 'restore' parental rights and to legislate parental control over minors' reproductive health care decisions remains active.

ccs cases

1.ectopic pregnancy- pt. presents to the clinic with lower abdominal pains,fever,n/v,and appears dehydrated.After the physicals and pelvic exam, the first thing i did was to order pregnancy test.It was positive in the clinic so I assume that ectopic pregnancy must be ruled out in the ER.Ultrasound confirmed the ectopic pregnancy.
2.hyperthyroidism-pt. presents to the clinic with tremors,tarchicadia and other sx i can't remember well.
3.chf new onset.

4.depression- a thirty something y.o. AA male was sent to your clinic by his wife who c/o of pt. being depressed and need medication.Pt. also c/o reduced sexual desires.All other history-fmhx,shx,pmhx and physicals are all normal.How do proceed from here.
I started the guy on zoloft and obtained all the basic labs-cbc, chem7,ua, testosterone level, tyroid level, and i asked him to come back in one week.He showed up saying he is feeling a little better,all his labs were noemal.I asked him to continued the zoloft and return in 2weeks but the computer prompted me by saying the guy is too busy to show up,it then asked me to give the final DX.
Could anybody comment on this particular ccs case.Should i have given the guy VIAGRA?

Which of the two elements that must present to make the Dx of primary aldosteronism
a. Adenoma in the zona flomerulosa and hypertension
b. abd bruit and hypertension
c. hypokalemia and elevated renin
d. hypokalemia and hypertension
e. Purple striae and dorsal hump

D

Primary aldosteronism:

Overview:
twice as common in women as in man
most often presents between 30 in 50 years of age

Most common cause:
adrenal adenoma -- excessive aldosterone production
unilateral adenoma (usually small; either side)
Conn's syndrome
Other causes:
hyperplastic adrenal glands -- abnormal secretion
malignant tumor
adrenal carcinoma (rare)

Physiological Effects of aldosterone hypersecretion:
increased renal distal tubule or exchange of sodium for secreted potassium and hydrogen ions -- body potassium depletion/hypokalemia

Diagnosis--Criteria:
diastolic hypertension (no edema)
renin hyposecretion (low plasma renin activity)
renin secretion does not increase with volume depletion
aldosterone hypersecretion that is not suppressed with volume expansion

Clinical Presentation:
diastolic hypertension (not very severe)
secondary to increase sodium reabsorption/volume expansion
headaches
polyuria, polydipsia
impairment of urinary concentrating ability
weakness
due to effects of potassium depletion
tetany
Electrocardiographic changes -- consistent with potassium depletion (hypokalemia-- which increases ectopy)
prominent U waves
cardiac arrhythmias
premature contractions
Many effects secondary to potassium loss associated with:
hypokalemia
may be severe (< 3 mmol/L)
hypernatremia-- due to:
sodium retention
water loss from polyuria
metabolic alkalosis-- due to
urinary hydrogen ion loss
movement of hydrogen ion into potassium-depleted cells
alkalosis enhanced by potassium deficiency which increases proximal convoluted tubule capacity to reabsorb filtered bicarbonate.

Treatment:
Due to adenoma -- usually treated surgically
may be treated by:
sodium intake restriction
aldosterone antagonist (spironolactone (Aldactone))
prolonged medical management (chronic therapy) may be side effect limited (males)
gynecomastia
decreased libido
impotence
Due to idiopathic bilateral hyperplasia
symptomatic hypokalemia treated by:
spironolactone (Aldactone)
triamterene (Dyrenium)
amiloride (Midamor)
surgery if pharmacological treatment fails

Barter's Syd=Hyper K +Normal BP+ Decr Na
Primary Ald=HTN+ Hypo K+Hyper Na
Secondary Ald=Incr Renin + decr K + HTN not prerequesite

Tx of thyroidism with levothyroxine or thyroxine takes how long to achieve full effect
A.1 week
B. 1 month
C. 2 month
d. 3 month
e 4 month

Due to the long half-life of levothyroxine, the peak therapeutic effect at a given dose of levothyroxine may not be attained for 4-6 weeks.

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Here is the cases I had last year.

1 25 yo female, at 10 weeks pregnancy
2 25 yo asian female nurse fatigue Dx anemia
3 70 yo duodenal ulcer w/ NSAID
4 70 yo Alzeheimer dementia
5 54 yo stable angina and HTN
6 15 yo vaginal bleeding
7 suicide amtyptlin overrdose
8 70 yo SOB did not response to Tx for COPD exacerbation, Possible PE
9 Hepatitis

Police brought this old baba of 65yrs old, wandering in the very cold weather with out any cloth out side his house. He lives alone after the death of his wife a year ago. Since he was unable to pay the electricity bill he was with out any heater in the house for three days. A friend of him finds out that he didt call for two days so he called the police to check on him. Patiuent condition is bcz:

a: Sever mental retardation.
b: Pathological grief reaction of her wife's death
c: Alcohol induce diorentation
d; Secondry to hypothermia.
e: Early onset alzahimer's disease

B

After a two day fever in a three yrs. old boy. examination in your office show some hyperemia in the pharynx and a genrealaized rash over the body.. tosills looks infected but no sheath. ther were few small palapabe mass in the front of neck no axilary or inguinal LN palpable. neck is supple. U satrt amoxill but the boy came back after five days with same fever.. he lost 2 pounds over 5 days with diarrhoea and dehydration. the fever now is 104F. you will

a: start third generation cephalosporin.
b: start Normal saline in D5W in your office and admit the patient in ward.
c: Start vancomycin as your first choice since he might have Cl. diff
d: Admit the patient in ICU
e) admit the patient in ward.

D

I think it is streptococcal toxic shock syndrome

Streptococcal TSS is characterized by hypotension and multiple organ failure. Considerable overlap occurs with streptococcal necrotizing fasciitis, insofar as most cases occur in association with soft tissue infections; however, streptococcal TSS may occur in association with other focal streptococcal infections, including pharyngeal infection.

Physicians need to be aware and concerned about the potential for life-threatening complications presented by group A streptococcal infections. Even seemingly minor infections (pharyngitis, impetigo) may lead to fatal toxic shock syndrome.

Any fever >101f should be monitored carefully,, if possible in ICU. In this case severity is TSS

You found that the girl is not talktive as she was one year ago when she appeared in the office with her mother. You try to find any reason but she kept her eyes down to the floor? Your examination was noncoclusive. You will tell the patient.

a) Its quite ok to be shy but you are just trying to help her
b) If she wants to talk in private.
c) Is something bothering her and is she willing to talk about it.
d) ask for home health agency to pay a visit in the
house.
e) Report to child protection agency.

B

You interview and exmaine the patient. your focus will be more on:

a) Evidence to find out sexual activity and advice for contraception
b) Evidence to find out any mental retardation.
c) Evidence for any long term effets of the trauma.. PTSD
D) Evidence of any psychological conflict and trauma

D

A 13 yrs old girl presented in your office in a rural area after one month of a car accident with pain in tha abdomen. She was unable to focus in the school since the accident and was mostly home bound. In the accident her mother fractured her femur and she is home bound too. The father of the girl ask you too sign a medical letter for the school and another one to the county to arrange a home tutor for her since she is unable to attend the school. You will

a: Tell the father that you will examine her first and then if u feel then you will write the letters.
b)Write both letters
c)write only letter for the school and not for the county for home teacher program
d) Focus on relevent inforamtion regarding her abdomenal pain

D

As an ER physician u received a call that a 18 yrs old boy is coming after an accident. You check the patient and bed side EEG is showing no activity. Considering for organ donation you check the ID and u see that he is enrolled for organ donation. Asian parents of the boy are in the ER and when they know about organ donation enrolment and that you are planning for it they get very upset. You will

a) Tell the paretns that what good this noble activity will bring in the life of those who will get the organs.
b) you will wait for another EEG.
c) Will tell the ER team to observe the patient for 24 more hours.
d) Proceede with the organ donation procedure since the boy is an adult.

D

Since brain death is a clinical diagnosis and physician is considering for organ donation.choices b and c are not likely
Asian parents are upset.and in this delicate situationi dont know may be a or d?

Which of the following is NOT a Tx for a patient with an acute gout attack
a. Ibuprofen
b. Aspirin
c. Colchicine
d. intraarticular steroid
e. Im steroid

B

Acute Gout: Treatment

Acute episodes are treated with NSAIDs. Ibuprofen 800 mg three to four times daily or Indomethacin 25 to 50 mg four times daily are often chosen because of their quick onset of action, but most NSAIDs can be used. The new selective COX-2 inhibitors (celecoxib, rofecoxib) should work as well, but have not been formally tested in controlled trials. Treatment should be discontinued when symptoms resolve.
In patients with contraindications to NSAID use, corticosteroids are the next choice. Intra-articular steriods are useful if only one or two joints are affected and the treating physician is proficient in injecting those joints. Oral prednisone can be used starting at 30-40 mg daily tapering over 10-14 days. Hospitalized patients can be given equivalent doses of corticosteroids intravenously.(ref 2)

Use of high dose colchicine either orally or IV is discouraged except in rare instances. High dose oral colchicine (1.2 mg followed by 0.6 mg every hour for 6 doses) is poorly tolerated because of GI side effects. IV colchicine (2 mg IV then 1 mg in 12 hours) is associated with serious toxcities including myopathy, neuropathy and aplastic anemia.

What not to do:
Do not depend on serum uric acid to diagnose acute gouty arthritis--it may or may not be elevated (> 8mg/ dl) at the time of an acute arthritis.
Do not use NSAIDs when a patient has a history of active peptic ulcer disease with bleeding. Relative contraindications include renal insufficiency, volume depletion, gastritis, inflammatory bowel disease, asthma and congestive heart disease.
Do not start maintenance NSAID doses for an acute inflammation. It will take a day or more to reach therapeutic levels and pain relief.
Do not insist upon re-confirming a diagnosis of gout in the ED by ordering serum uric acid levels (which are often normal during the acute attack) or tapping an exquisitely painful joint in a patient with known gout.
Do not, during an acute attack of gouty arthritis, attempt to reduce the serum uric acid level with probenecid, allopurinol, or sulfinpyrazone. This will not help the arthritis, and may even be counterproductive. Leave it for follow up.
Do not, use asprin because of its side effects.