A 65-year-old man, his wife, and 38-year-old son have been your clinic patients for the last 15 years. In the evaluation of some mild hemoptysis of the 65-year-old man, a chest x-ray reveals a 4 cm right sided lung mass, hilar and mediastinal adenopathy, and several lytic lesions in his ribs and humerus. None of these findings were present on an x-ray performed 4 years earlier. He has a 50-pack year smoking history. When he returns to your office, you inform him that he likely has stage IV lung cancer and that you would like to refer him to an oncologist for further evaluation. He states that he wants no therapy whatsoever, and that he wants to keep this a secret from his family. The most appropriate response would be to
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/ A. call his son as soon as he leaves the office
/ B. inform him that treatment will likely be curative and that he should really reconsider his decision
/ C. investigate what it is that makes him feel uncomfortable in telling his family and provide counseling
/ D. realize that he will likely "come to his senses" and give him a referral to the oncologist anyway
/ E. tell him that he is probably just in denial and try to persuade him to tell his wife when he gets home
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Explanation:
The correct answer is C. Patient confidentiality is one of the most important medical ethical issues facing physicians, and it certainly can pose dilemmas at times. This patient has just received horrible news and is likely just reacting without really thinking about the ramifications of his decision. However, there may be very important personal, social, or cultural reasons for his decision. It is important for you, as a physician, to explore these with him.
Calling his son (choice A) is inappropriate because it breaks confidentiality.
Although you will likely try to get the patient to reconsider his decision (choice B) telling him that therapy will likely be curative for stage IV lung cancer is not true. There is very little chance at a cure and palliative therapy is a much more reasonable expectation.
Giving him a referral to the oncologist because he is will "come to his senses" (choice D) is inappropriate. He obviously needs counseling, and the feelings as to why he does not want treatment and why he does not want his family to know, should be explored.
Although the patient may be in denial (choice E), patient confidentiality precludes you from unilaterally deciding to tell his wife. It is appropriate to try to understand the reasons why he does not want to tell his family, as opposed to trying to persuade him to tell his wife when he gets home.
A 24-year-old woman comes to the office because of a cough with "yellowish sputum production" for the past 2 days. She states that the cough has been keeping her up at night and it is bothering her co-workers. They insisted that she "go get medicine" so that she does not "infect the entire office." She has no history of respiratory disease. Her temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is 70/min, and respirations are 18/min. Physical examination is normal. The most appropriate next step in management is to
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/ A. admit her to the hospital for medical management
/ B. obtain a sputum culture
/ C. order a chest x-ray
/ D. prescribe erythromycin, orally
/ E. send her home with no medications
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Explanation:
The correct answer is E. This patient most likely has acute bronchitis. Acute bronchitis in a healthy patient with no other medical conditions is often due to viral infection that is usually self-limited. Given that this patient has only had 2 days of symptoms, an antibiotic is not necessary and is inappropriate. If the symptoms persist for longer than 1 week, a macrolide antibiotic may be given. A chest x-ray and a sputum culture are not indicated.
Admission to the hospital for medical management (choice A) is inappropriate for a healthy patient with acute bronchitis.
A sputum culture (choice B) is used to identify organisms, but should only be used in an elderly patients with chronic disease that fail antibiotic therapy. This patient's acute bronchitis is most likely due to a self-limited viral infection.
A chest x-ray (choice C) has no role in the diagnosis of acute bronchitis in a healthy patient.
Send the patient home with antibiotic therapy (choice D) is appropriate management for acute bronchitis in an elderly patient with chronic disease. A macrolide (erythromycin, azithromycin, clarithromycin) is the treatment of choice. It is not part of the initial treatment in a previously healthy patient.
A 45-year-old woman with severe reflux disease secondary to a hiatal hernia is admitted to the hospital with flank pain from a kidney stone. An abdominal CT shows multiple stones in the right ureter and renal pelvis. On the floor, she is given intramuscular meperidine every 4 hours for pain control. Early in the morning the patient is found to be obtunded in moderate respiratory distress with some evidence of vomitus on her lips and bed shirt. She had been given 3 additional doses of meperidine for pain control in the past 5 hours. A chest radiograph will most likely show a
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/ A. diffuse bilateral airspace disease
/ B. diffuse bilateral interstitial infiltrates
/ C. right lower lobe opacification
/ D. right pleural effusion
/ E. widened mediastinum
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Explanation:
The correct answer is C. Aspiration of gastric contents causes severe lung inflammation. The traditional dogma that the acidic nature of the aspirate is critical has recently been reevaluated and it is now clear that large volumes of gastric contents of any pH are dangerous to the lung. Patients with severe reflux often regurgitate frequently throughout the day and at night will have small aspiration events, which will wake them from sleep by coughing. Once sedated, these people develop depressed cough reflexes and therefore are more likely to be unable to protect their airway during such regurgitations. This is most certainly what has occurred with this patient. The most common radiological finding is right lower lobe opacification (alveolar filling) or collapse.
Diffuse bilateral airspace disease (choice A) is characteristic of acute respiratory distress syndrome (ARDS) or very late stage aspiration which can lead to ARDS.
Diffuse bilateral interstitial infiltrates (choice B) are characteristic of pulmonary edema. This may be a late manifestation (a few days) of severe aspiration, but not an early one.
Pleural effusions (choice D) are not present in aspirations. A unilateral effusion can be found in cases of liver abscess or right sided diaphragmatic irritation or with Meigs syndrome (ovarian cancer and ipsilateral pleural effusion).
A widened mediastinum (choice E) is characteristic of an aortic arch dissection or of a pulmonary disease such as sarcoid.
A 78-year-old man who lives alone is brought to the emergency department by ambulance because of respiratory distress. According to the brief history obtained by the paramedics, he is having abdominal pain since the morning and reports a history of congestive heart failure, insulin dependent diabetes mellitus, hypertension, and peripheral vascular disease. On arrival to the hospital, he is very drowsy and his temperature is 36.7 C (98.0 F), pulse is 110/min and irregular, blood pressure is 90/54 mm Hg, respirations are 24/min, and oxygen saturation is 84%. He appears to be in great distress from his abdominal pain. Laboratory studies show:
After starting an intravenous catheter and administering a diuretic, you are getting ready to intubate the patient. The emergency department nurse conveys a message from the patient's daughter in Florida that there is a living will written by the patient which mandates that under no circumstances should he be intubated, resuscitated by CPR or dependent on artificial ventilation or feeding. The nurse reports that the daughter was very emotional and adamant that the patient should just be made comfortable, and that she would sue if he was intubated or if CPR carried out. During that emotional conversation she forgot to leave her phone number. The most appropriate next step in management is to
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/ A. call a hospital administrator to make a decision
/ B. call a hospital lawyer for advice
/ C. intubate the patient
/ D. respect the daughter's wishes and keep the patient comfortable without intubation
/ E. try and trace the daughter's phone number and request a fax of the living will
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Explanation:
The correct answer is C. The patient is in respiratory distress and needs intubation for airway control, better oxygenation, hemodynamic resuscitation, and to feel comfortable. Although every attempt should be made to respect the patient's wishes and the family's requests, in an emergency situation there is limited opportunity to check the validity of telephone messages and faxed documents. Medical emergency mandates appropriate action prior to legal concerns.
Calling the hospital administrator (choice A) and lawyer (choice B) are not advisable in an emergency situation for the reasons explained above.
A living will mandating “do not resuscitate or do not intubate” needs to be checked and certified by a hospital social worker or legal department for authenticity before implementation. In an emergency situation this is not practical. Even if this patient is intubated, once a valid living will is obtained the ventilator can be switched off. Hence, to respect the daughter's wishes and keep the patient comfortable without intubation (choice D) is incorrect.
To try and trace the daughter's phone number and request a fax of the living will (choice E) is not practical in an emergency situation, and the validity of the documents is questionable without being checked by hospital authorities.
A 29-year-old man is admitted to the hospital with fever and cough. The symptoms began roughly 1-month prior and have been intermittent. He states that his cough is often productive of thick secretions and that, despite normal food intake, he has lost about 10 pounds in the past month. He is a volunteer at a local hospital and has received no special health care personnel vaccinations or screening tests. On examination, the patient appears somewhat thin, tired, and is coughing intermittently. His temperature is 38.0 C (100.4 F) and respirations are 16/min. He has patchy bilateral rhonchi over all lung fields. Prior to initiating therapy for this condition, the laboratory test required to confirm the suspected diagnosis is a
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/ A. chest radiograph
/ B. sputum acid-fast stain
/ C. sputum culture
/ D. sputum Gram stain
/ E. tuberculin skin test
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Explanation:
The correct answer is B. The patient likely has tuberculosis. Virtually all M. tuberculosis is transmitted by airborne particles that are 1 to 5 µm in diameter. The symptoms of tuberculosis are protean and nonspecific and can be classified as either systemic or organ-specific. Classic systemic symptoms include fever, night sweats, anorexia, weight loss, and weakness. However, since tuberculosis is associated with other illnesses that have similar symptoms, this lack of specificity can result in a delayed diagnosis or even a misdiagnosis. Organ-specific symptoms of pulmonary tuberculosis include cough, pleuritic pain, and hemoptysis. The requirement for diagnosis is the presence of the organism that appears by acid-fast staining in a sputum sample.
In patients with primary tuberculosis, chest radiographs (choice A) often show infiltrates in the middle or lower lung zones, with ipsilateral hilar adenopathy. These findings are non-specific and are not used for confirmation of the diagnosis.
A sputum culture (choice C) is not useful in this case since the organism responsible for TB is fastidious and is difficult to culture, and certainly does not grow rapidly.
The organism responsible for TB does not stain with traditional Gram stain dyes (choice D) and therefore requires special staining such as acid-fast in order to detect it.
Although it is imperfect, the gold standard for diagnosing latent tuberculosis infection remains the intradermal injection (choice E) of purified protein derivative (5 TU) into the volar or dorsal surface of the forearm (Mantoux method). The test has no role in the diagnosis of active infection.
A 56-year-old man comes to the clinic for a pre-employment physical examination. He feels well and denies any health problems. Past medical history is negative except for an appendectomy about 20 years ago. The patient drinks several alcoholic beverages per day and smokes "a lot" of cigarettes. A "screening" chest x-ray, which you ordered because it is asked for on the employment forms, is shown below and demonstrates a left hilar mass and emphysema.
In considering the most appropriate next step in management, the most relevant question to ask this patient at this time is:
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/ A. "Are your affairs in order?"
/ B. "Do you have any allergies?"
/ C. "How many packs of cigarettes do you smoke per day?"
/ D. "What are your thoughts on end of life care?"