Updated: 9/29/2018

Legal Principles

Topic
Review Topic
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Questions
32
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Evidence
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Introduction
  • The following principles are intended to be applied only to a variety of individual situations you may face on the USMLE
Capacity, Competence, and Consent
  • Capacity vs competence 
    • capacity is a medical term
    • competence is a legal term
  • Competent patients have the right to refuse medical information and medical treatment(s) 
    • a feeding tube is a medical treatment
    • a competent person can refuse lifesaving hydration or nutrition 
  • Assume that the patient is competent unless 
    • history of suicide attempt
    • psychotic
    • patient cannot communicate
  • Obtain informed consent
    • patient must understand 
      • risks
      • benefits
      • alternatives
        • including no treatment 
    • patient must agree with plan of care without coercion
    • exceptions
      • emergencies  
      • waiver by patient
      • patient lacks decision-making capacity 
      • therapeutic privilege
        • physician deprives an unconscious or confused patient of his autonomy in order to protect the patient's health (paternalism)
    • note that written consent can be revoked orally at any time 
    • components of informed consent include:
      • patient makes and communicates a choice
      • patient is informed
        • information has not been withheld from the patient
      • decision remains stable over time
      • decision is consistent with patient's values and goals
      • decision is not result of delusions or hallucinations
    • consent from a patient's spouse is not required treatment of a patient with capacity  
End-of-Life Issues
  • If the patient cannot make decisions, surrogate decision makers must use the following criteria:
    • subjective standard (advance directive of patient) 
      • living will = patient provides specific instructions to withhold or withdraw life-sustaining treatment
    • substituted judgment (what would the patient want) 
      • durable power of attorney = patient designates healthcare proxy to make decisions
      • supersedes living will if both exist
    • "best interests" of the patient 
    • when no living will or durable power of attorney exists, the clinician is responsible for determining an appropriate surrogate decision maker from available family members 
      • the priority of next-of-kin for surrogate decision making is as follows:
        • legal guardian appointed by a court
        • spouse
        • adult children (> 18 yrs)
        • parents
        • adult siblings 
        • grandparents/grandchildren
        • friend of the patient
  • Euthanasia
    • passively allowing patient to die is acceptable
      • but do everything you can to relieve patient's suffering
    • active killing of the patient is not acceptable
  • when treatment should stop
    • physician thinks treatment is futile but family insists on treatment
      • continue treatment
    • after declaraion of brain death but family insists on treatment
      • stop treatment
Confidentiality
  • Confidentiality between physician and patient is generally absolute      
    • exceptions
      • suspicion of child/elder abuse
      • gunshot or stabbing injuries must be reported to the police
      • communicable disease must be reported
      • the patient is a harm to others or self
        • tarasoff decision 
      • no alternative means exists to warn others
      • patient waves right to privacy
        • e.g. for insurance purposes
Minors
  • Minors cannot give informed consent unless emancipated through:
    • marriage
    • a parent  
    • military service
    • living alone
  • A minor's refusal of treatment can be overruled by a parent 
  • Parents cannot withhold life- or limb-saving treatment from their children, but can refuse other treatments 
  • Examples
    • 17-year-old girl whose parents cannot be contacted
      • physician may treat a threat to health under in locum parentis
    • 17-year-old girl living on her own
      • patient can choose whether or not to give consent
    • 17-year-old girl who is requests birth control 
      • provide access even in absence of parental consent
    • 17-year old girl who requests treatment for an STI
      • notification of parents is not required 
    • 16-year-old girl refuses but mother consents
      • treat
    • 16-year-old girl consents but mother refuses
      • do not treat
Other Principles
  • Avoid going to court
  • Use trained medical interpreters when possible  
  • Committed mentally ill patients retain their rights
  • Never abandon a patient
    • transferring a patient to another physician's care is rarely (if ever) a correct answer on the USMLE
    • If a treatment (such as abortion, birth control, etc) is against a physician's personal beliefs - that physician does not have to provide that treatment; however, they are responsible for referring their patient to a provider who is willing and able to provide such care 
  • Disclose all errors, regardless of harm   
    • consulting risk management alone is rarely (if ever) a correct answer on USMLE
Child and Elder Abuse
  • If suspected abuse is occurring, physicians are mandated reporters and MUST report  
 

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Questions (32)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.ST.10) A patient is unresponsive in the emergency department following a motor vehicle accident. The patient's written advance directive states that he does not wish to be resuscitated in the event of a cardiac arrest. The patient's wife arrives and demands that "everything" be done to keep him alive because she "can't go on living without him." The patient's adult son is on his way to the hospital. If the patient arrests, which of the following should occur? Review Topic

QID: 100010
1

Respect the wife's wishes and resuscitate the patient

2%

(4/181)

2

Respect the patient's prior wishes and do not resuscitate

90%

(163/181)

3

Allow the patient's adult son to make the final decision on whether or not to resuscitate

1%

(1/181)

4

Consult a judge for the final decision on whether or not to resuscitate

2%

(3/181)

5

Consult the hospital ethics committee

2%

(3/181)

M1

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PREFERRED RESPONSE 2
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(M1.ST.74) A 33-year-old male is brought by ambulance to the emergency room after being a passenger in a motor vehicle accident. An empty bottle of whiskey was found in his front seat, and the patient admits to having been drinking all night. He has multiple lacerations and bruising on his face and scalp and a supportive cervical collar is placed. He is stabilized and is transported to the CT scanner. While there, he states that he does not want to have a CT scan and asks to be released. What is the most appropriate course of action? Review Topic

QID: 106603
1

Release the patient as requested

2%

(2/126)

2

Explain to him that he is intoxicated and cannot make health care decisions, continue as planned

72%

(91/126)

3

Have the patient fill the appropriate forms and discharge against medical advise

11%

(14/126)

4

Call security

3%

(4/126)

5

Agree to not do the CT scan

6%

(8/126)

M1

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PREFERRED RESPONSE 2
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(M1.ST.4766) A 44-year-old female patient comes to the physician’s office with her husband with complaints of abdominal pain. For the past 4 months, she has experienced cramping right upper quadrant pain that starts after meals. The physician performs a right upper quadrant ultrasound that shows round echogenic masses in the gallbladder. The physician offers an elective cholecystectomy to the patient to improve her symptoms and explains the procedure in detail to the patient including potential risks and complications. The patient acknowledges and communicates her understanding of her diagnosis as well as the surgery and decides to proceed with the surgery in one month. The patient signs a form indicating her consent to this procedure. Which of the following must also be communicated to the patient at this time? Review Topic

QID: 109091
1

A family member must also provide consent for this procedure

2%

(2/94)

2

The patient must give consent again before the procedure

4%

(4/94)

3

The patient has the right to revoke her consent at any time before the procedure

84%

(79/94)

4

The patient’s consent was not necessary for this procedure

0%

(0/94)

5

The results of the procedure must be disclosed to her husband

2%

(2/94)

M1

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PREFERRED RESPONSE 3
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(M1.ST.73) A 43-year-old male is admitted to the hospital for a left leg cellulitis. He is being treated with clindamycin and is recovering nicely. On the second day of his admission, a nurse incorrectly administers 100 mg of metoprolol which was intended for another patient with the same last name. The error is not discovered until the next day, at which time it is clear that the patient has suffered no ill effects of the medication and is not aware that an error has occurred. What is the proper course of action of the attending physician? Review Topic

QID: 106590
1

Immediately disclose the error to the patient

66%

(27/41)

2

Notify hospital administration but do not notify the patient as no ill effects occurred

2%

(1/41)

3

Do not disclose the error to the patient as no ill effects occurred

0%

(0/41)

4

Tell the nurse who administered the drug to notify the patient an error has occurred

10%

(4/41)

5

Make a note in the patient's chart an error has occurred but do not disclose the error to the patient

5%

(2/41)

M1

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PREFERRED RESPONSE 1

(M1.ST.73) A 76-year-old Spanish speaking male comes to the health clinic with his daughter for a routine health maintenance visit. The physician speaks only basic Spanish and is concerned about communicating directly with the patient. The patient's daughter is fluent in both English and Spanish and offers to translate. The clinic is very busy, but there are usually Spanish medical interpreters available. What is the best course of action for the physician? Review Topic

QID: 106574
1

Use the daughter as an interpreter

10%

(4/40)

2

Request one of the formal interpreters from the clinic

60%

(24/40)

3

Attempt to communicate using the physician's basic Spanish

2%

(1/40)

4

Converse with the patient in English

2%

(1/40)

5

Suggest that the patient finds a Spanish speaking physician

0%

(0/40)

M1

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PREFERRED RESPONSE 2

(M1.ST.73) A 17-year-old girl comes to your outpatient clinic. She is sexually active with multiple partners and requests a prescription for oral contraceptive pills. A urine pregnancy test in your office is negative. Which of the following is the most appropriate next step? Review Topic

QID: 106573
1

Contact the patient's parents to obtain consent

0%

(0/18)

2

Recommend sexually-transmitted infection screening and provide the requested prescription

50%

(9/18)

3

Refer the patient for counseling and recommend sexually-transmitted infection screening

11%

(2/18)

4

Perform urine drug screen

0%

(0/18)

5

Advise against oral contraceptive medications and recommend condom use instead

6%

(1/18)

M1

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PREFERRED RESPONSE 2

(M1.ST.73) A 73-year-old man presents to his primary care physician endorsing 4-5 days of decreased urinary output and mild shortness of breath. He has a complex medical history, including uncontrolled diabetes mellitus type 2, hypertension, chronic kidney disease, and end-stage emphysema. It is determined that his kidney disease has progressed to the point of needing dialysis, which his primary care physician feels should be initiated promptly. However, the patient remarks, "I would never want dialysis. I have friends who went through it, and it sounds awful. I would rather die comfortably, even if that is soon." After the physician explains what dialysis is, and the risks and alternatives to the procedure the patient is able to demonstrate his understanding of dialysis including the risks, benefits and alternatives. He appears to be in no distress and demonstrates a clear understanding. After discussing the patient's wishes further, which of the following is the most appropriate response on the part of the physician? Review Topic

QID: 106580
1

"I will obtain an ethics consultation to help with this matter"

0%

(0/18)

2

"I will involve a psychiatrist to help determine your capacity to refuse this treatment"

0%

(0/18)

3

"I cannot be your physician going forward if you refuse to undergo dialysis"

0%

(0/18)

4

"I strongly encourage you to reconsider your decision"

0%

(0/18)

5

"I respect that this is ultimately your decision, and will focus on making sure you are comfortable"

67%

(12/18)

M1

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PREFERRED RESPONSE 5
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(M1.ST.41) An 86-year-old male is admitted to the hospital under your care for management of pneumonia. His hospital course has been relatively uneventful, and he is progressing well. While making morning rounds on your patients, the patient's cousin approaches you in the hallway and asks about the patient's prognosis and potential future discharge date. The patient does not have an advanced directive on file and does not have a medical power of attorney. Which of the following is the best course of action? Review Topic

QID: 102982
1

Explain that the patient is progressing well and should be discharged within the next few days.

0%

(0/15)

2

Provide the cousin with the patient's most recent progress notes and a draft of his discharge summary.

0%

(0/15)

3

Direct the cousin to the patient's room, telling him that you will be by within the hour to discuss the plan.

7%

(1/15)

4

Refer the cousin to ask the patient's wife about these topics.

0%

(0/15)

5

Explain that you cannot discuss the patient's care without explicit permission from the patient themselves.

60%

(9/15)

M1

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PREFERRED RESPONSE 5

(M1.ST.19) A 40-year-old woman is admitted to the hospital about four hours after her husband discovered that she ingested a bottle of acetaminophen in an attempted suicide. The patient denies any symptoms at this time. Vital signs include a blood pressure of 115/80 mmHg and pulse of 85/min. Physical exam is unremarkable. AST and ALT levels are approximately 2500 U/L. APAP level is 160 mcg/mL, and INR is 1.7. The patient refuses N-acetyl-cysteine (NAC) treatment. What is the best next step in management? Review Topic

QID: 100019
1

Administer NAC

19%

(6/32)

2

Cancel the NAC order

9%

(3/32)

3

Involve the patient's husband to guide medical care

22%

(7/32)

4

Force the patient to accept NAC

6%

(2/32)

5

Consult psychiatry

25%

(8/32)

M1

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PREFERRED RESPONSE 3

(M1.ST.83) A 29-year-old man develops dysphagia after sustaining a stroke secondary to a patent foramen ovale. He is only able to swallow thin liquids. He has lost 10 pounds because of limited caloric intake. The medical team recommends the placement of a feeding tube, but the patient declines. The patient also has a history of major depressive disorder with psychotic features, for which he has been treated with fluoxetine. He is alert and oriented to person, place, time and situation. He denies any visual or auditory hallucinations, suicidal ideation, guilt, or sadness. He can articulate to the team the risks of not placing a feeding tube, including aspiration, malnutrition, and even death, after discussion with his medical team. The medical team wishes to place the feeding tube because the patient lacks capacity given his history of major depressive disorder with psychotic features. Which of the following is true regarding this situation? Review Topic

QID: 105753
1

The patient lacks capacity and the feeding tube should be placed

0%

(0/27)

2

The patient lacks capacity and his healthcare proxy should be contacted regarding placement of a feeding tube

26%

(7/27)

3

The patient lacks capacity and the state should determine whether to place the feeding tube

0%

(0/27)

4

The patient has capacity and may deny placement of the feeding tube

44%

(12/27)

5

The hospital ethics committee should determine whether to place the feeding tube

11%

(3/27)

M1

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PREFERRED RESPONSE 4

(M1.ST.5) On physical examination and imaging, a 3-year-old male shows evidence of multiple healed fractures and bruising. On eye exam, the child's irises appear blue, and results of a fundoscopic exam are shown in Image A. What is the most appropriate next step in the care of this patient? Review Topic

QID: 100005
FIGURES:
1

Intravenous vitamin C

4%

(5/117)

2

Genetic testing for collagen synthesis disorder

41%

(48/117)

3

Call child protective services

44%

(51/117)

4

Hearing test

7%

(8/117)

5

Bone marrow transplant

0%

(0/117)

M1

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PREFERRED RESPONSE 3

(M1.ST.24) You are a resident on a pediatric service entering orders late at night. Upon arrival the next morning, you note that you had mistakenly ordered that low molecular weight heparin be administered to a 17-year-old patient who does not need anti-coagulation. When you talk to her, she complains about the "shot" she had to get this morning but is otherwise well. How should you handle the situation? Review Topic

QID: 100024
1

You cannot disclose the error as a resident due to hospital policy

0%

(0/14)

2

Tell the patient, but ask her not to tell her parents

0%

(0/14)

3

Speak to risk management before deciding whether or not to disclose the error

7%

(1/14)

4

Tell the patient and her parents about the error

57%

(8/14)

5

Since there was no lasting harm to the patient, it is not necessary to disclose the error

0%

(0/14)

M1

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PREFERRED RESPONSE 4

(M1.ST.51) A 2-week-old infant is brought to the pediatrician for the first time by his parents. His mother received regular prenatal care and the child was born at home under the guidance of a midwife and a doula. The child appears well. The parents tell you they do not plan to have their child receive any vaccines. After a discussion regarding the risks and benefits of vaccines, the parents are still adamant in their wishes to forgo. Which of the following is the most appropriate course of action? Review Topic

QID: 105721
1

Call child protective services

6%

(1/18)

2

Refuse to continue to care for the child

0%

(0/18)

3

Seek a court order to deliver the vaccines against the wishes of the parents

0%

(0/18)

4

Give any scheduled vaccines during that visit against the will of the parents

0%

(0/18)

5

Document the visit, specifically the detailing of risks and benefits and the parents' refusal of treatment

67%

(12/18)

M1

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PREFERRED RESPONSE 5
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(M1.ST.39) A 79-year-old male presents to your office for his annual flu shot. On physical exam you note several linear bruises on his back. Upon further questioning he denies abuse from his daughter and son-in-law, who live in the same house. The patient states he does not want this information shared with anyone. What is the most appropriate next step, paired with its justification? Review Topic

QID: 100039
1

Breach patient confidentiality, as this patient's care should be discussed with the daughter as she is his primary caregiver

0%

(0/18)

2

Breach patient confidentiality, as this patient is a potential victim of elder abuse and that is always reportable

72%

(13/18)

3

Do not break patient confidentiality, as this would potentially worsen the situtation

0%

(0/18)

4

Do not break patient confidentiality, as elder abuse reporting is not mandatory

0%

(0/18)

5

See the patient back in 2 weeks and assess whether the patient's condition has improved, as his condition is not severe

0%

(0/18)

M1

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PREFERRED RESPONSE 2
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(M1.ST.12) You are the attending physician on duty on an inpatient hospitalist team. A 48-year-old patient with a history of COPD and atrial fibrillation on warfarin is admitted to your service for management of a COPD exacerbation. Four days into her admission, routine daily lab testing shows that patient has an INR of 5. She is complaining of blood in her stool. The bleeding self-resolves and the patient does not require a transfusion. Review of the medical chart shows that the patient's nurse accidentally gave the patient three times the dose of warfarin that was ordered. What is the correct next step? Review Topic

QID: 103610
1

Tell the patient that a mistake was made and explain why it happened

64%

(9/14)

2

Tell the patient that the blood in her stool was likely a side effect of the warfarin

0%

(0/14)

3

Do not tell the patient about the mistake as no harm was done

0%

(0/14)

4

Do not tell the patient about the mistake because she is likely to sue for malpractice

0%

(0/14)

5

Do not tell the patient about the mistake because you did not make the mistake

0%

(0/14)

M1

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PREFERRED RESPONSE 1
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(M1.ST.11) A 32-year-old male asks his physician for information regarding a vasectomy. On further questioning, you learn that he and his wife have just had their second child and he asserts that they no longer wish to have additional pregnancies. You ask him if he has discussed a vasectomy with his wife to which he replies, "Well, not yet, but I'm sure she'll agree." What is the next appropriate step prior to scheduling the patient's vasectomy? Review Topic

QID: 100011
1

Insist that the patient first discuss this procedure with his wife

14%

(2/14)

2

Telephone the patient's wife to inform her of the plan

0%

(0/14)

3

Explain the risks and benefits of the procedure and request signed consent from the patient

36%

(5/14)

4

Refuse to perform the vasectomy

0%

(0/14)

5

Explain the risks and benefits of the procedure and request signed consent from the patient and his wife

14%

(2/14)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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Topic COMMENTS (31)
Private Note