Saturday, 10 November 2012

Usmle Step 1 MCQ's # 2

Title: Usmle Step 1 MCQ's # 2
Subject: Behavioral Science

Q NO 2: A 25-year-old woman is brought to the hospital by her husband. The patient complains of severe pain and tenderness in her lower left abdomen. She is diagnosed with appendicitis and scheduled for an emergency appendectomy under general anesthesia. A 2nd year resident performs her surgery. Surgery reveals that the appendix is normal and without inflammation. However, the resident notices a large tumor attached to the patient’s left ovary At this point the resident’s best next course of action would be to do which of the following?

A. Biopsy the tumor and terminate the surgery
B. Excise as much of the tumor as possible without coming into contact with the ovary?
C. Exercising common standards of care, remove the patient’s ovary to eliminate the tumor
D. Seek permission to excise the tumor from the patient’s husband, who is sitting in the waiting room
E. Seek the advice of the supervising surgeon
F. Talk with the patient’s husband, who is in the waiting room, about how his wife would probably want to proceed

The correct answer is A. A competent patient has the right to make all treatment decisions for themselves, including refusal of treatment. If you can access the patient’s wishes by direct conversation, then this must be done. After woman recovers from the anesthesia, she is entitled to full informed consent including descriptions of the: 1) nature of the procedure, 2) the purpose or rationale, 3) the benefits, 4) the risks, and 5) the availability of alternatives. With this information presented, the patient herself can make whatever treatment decision seems best to her.
Excising the tumor (choice B) is treatment without the patient’s consent and permission.
Patient’s wishes, not” common standards of care” (choice C), are what guide treatment decisions. Only if we could not access the patient’s wishes in any way, AND the situation was critical, would we act using judgment as to what would be reasonable care.
Choices D and F are incorrect, because the woman has primary say over her own body. If she were in a coma of some duration, then we might ask the husband under the doctrine of substituted judgment. But here, we can wake her up and ask her directly.
The resident has all of the information required to know the correct actions to take without consulting a superior (choice E). In general, consulting a superior will be the wrong answer on the Step 1 exam.

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