Small Group Session 18

January 23rd or January25th

TRUTHTELLING CASE AND HEENT WORKSHOP

Readings:

-Ahronheim, Moreno and Zuckerman, Ethics in Clinical Practice 2nd ed,

“Don’t tell mother” (in your appendix)

-Review lectures notes from “Truthtelling lecture.”

-Complete the HEENT module available on the POM web-site

-Review OSCE sheets for HEENT exam.

Prepare by: charging otoscope handle

Bring:

-Bring otoscope, stethoscope, and tuning fork.

-Mentors, bring pads, cleaning supplies, tongue blades, otoscope speculae, and cups and water for thyroid examination.

Brief Outline:

Section 1: Touch base

Section 2: Truthtelling case

Section 3: HEENT Workshop

Small Group Session 18

Section 1: Touch base

Section 2: Truthtelling case - A patient with trouble swallowing. (60minutes)

Objectives:

  • to discuss a case which raises issues of truthtelling and confidentiality

A PATIENT WITH TROUBLE SWALLOWING:

A 65 year old woman comes to you for trouble swallowing for two and a half months. She has always had trouble with heartburn. About three months ago, her heartburn seemed to get worse and she started having pain with swallowing solid foods. Since then the pain has worsened and she now has discomfort with eating soft foods, and it is becoming harder to swallow. The discomfort is located in upper chest, in the mid-line.

She has become afraid to eat and has lost her appetite, so she has lost 10 pounds in 2 months.

She called you almost two months ago because of these symptoms and received a prescription for Nexium over the phone. It did not help.

Past medical history: mild high blood pressure on no regular medications. Chronic heartburn that she has treated with over the counter antacids. No other prescription or over-the-counter medications.

Social history: she is happily married with one son. She quit smoking ten years ago. She has 1 or 2 drinks a day before dinner, but has never had a drinking problem. CAGE questions have been negative.

Family history: Her father (a smoker) died of lung cancer, and her mother died of stomach cancer.

Physical examination:

On examination, your patient appears chronically ill. HEENT exam is normal, except for bilateral supraclavicular adenopathy. Cardiac and chest examination are normal. Abdominal exam is normal.

1. What are the important history and physical findings? What could they mean?

2. What are some diagnostic possibilities?

Lab findings:

You order an esophagoduodenoscopy (EGD) and a CAT scan of the abdomen and chest. The EGD shows a large, circumferential ulcerated mass in the mid-esophagus. Biopsy shows squamous cell carcinoma. CAT scan shows extension of the tumor through the wall of the esophagus into mediastinal structures, mediastinal lymphadenopathy, and celiac (retrogastric) lymphadenopathy. (This generally denotes extensive disease that is not amenable to surgical resection, with a very poor prognosis).

You schedule an appointment to see your patient to discuss the possibilities and your recommendations. You have recommended that she bring a family member or close friend to the appointment; she has brought her son. As you prepare to enter the room, her son meets you in the hall and asks to talk with you privately.

He explains that his mother has a history of severe depression that once required hospitalization. He wants to know her diagnosis and admits he fears that it is cancer. He is very worried about how she will react if she learns she has cancer. “It would kill her,” he says. “She would just give up and die if you told her she has cancer. And I’m not sure she has the strength for chemotherapy in any case. If it’s cancer, please, for her sake, just take it out and say it’s something else.”

Ethics discussion:

The major issue here is truth-telling (related to patient autonomy), but the case also raises issues of confidentiality and beneficence.

  1. Under what circumstances can you tell her son her diagnosis?
  1. What exactly is your duty to tell patients? How about if you don’t know yet?
  1. In what circumstances can you ethically not tell the patient her diagnosis?
  1. Must you tell patients the diagnosis if they ask not to be told?
  2. Should you tell a patient when you think you might have made an error?
  1. Is there evidence that informing patients of a cancer diagnosis harms them?

If it isn’t already clear: go around the room and ask each person what they would advise the physician in this situation.

Section 3: HEENT examination workshop (75 minutes)

Objectives: to learn the technique of examining head, eyes, ears, nose, throat and neck

Logistics:

● Mentor demonstrates HEENT exam. Group can decide if they want to do one at a time, or demonstrate both in sequence.

● Practice today the techniques on the HNE and ENT OSCEs. While you are there, look for some landmarks. Your examination may include:

  • Inspection of head and scalp for symmetry, facial weakness, deformities, scars, hair distribution, etc.
  • Inspection of ears
  • Pinnae and external auditory canals
  • Otoscope technique
  • Viewing the tympanic membrane
  • Tests of hearing (finger rub or whisper, Weber and Rinne)
  • Inspection of nose: patency and turbinates
  • Inspection of mouth and throat:
  • Mucosal color and moistness
  • Normal variants
  • Teeth and gums
  • Tongue (include Vallate papillae)
  • Salivary duct openings
  • Uvula
  • Soft and hard palate
  • Tonsils
  • Palpation: for
  • Sinus tenderness
  • Temporal arteries
  • Parotid and submandibular salivary glands

Examination of the neck:

  • Inspection: for symmetry, masses
  • Palpation: of
  • Trachea
  • Cricoid cartilage
  • Hyoid bone
  • Carotid pulses
  • Thyroid gland
  • Lymph node palpation:
  • Preauricular
  • Postauricular
  • Tonsillar
  • Submandibular
  • Submental
  • Anterior cervical
  • Occipital
  • Posterior cervical
  • Supraclavicular

Section 4: Evaluate session

How did this session go? What could make it work better in the future?