CLINICAL FORUM:

Core of Ethics:
Beneficence- do what is best for the patient
Maleficence- first do no harm
Autonomy- respect patients right to self-determination
informed consent and confidentiality
Justice-be fair to all concerned, whats good for Pt and whats good for everyone else
not using up all resources because other Pt would receive better or equal quality of life
law is ethical minimum
We take a value laden approach to healthcare delivery
Three kinds of error
technical error- we fall short technically
judgement error- incorrect strategy
normative error- technically competent, good strategy, and good moral sense, but error still occurs
The Medical Interview
Develop relationship
first impression
knock first
introduce yourself
wash hands in room
stand to patients right
Respect Patient
Empathize (does not mean compassion)
Be genuine
DR/Pt Relationship Models
paternalistic-dr in charge, ex: im going to give you Ab (good for Emergency)
comsumer-pt in charge, ex: I want Ab
shared decision making- negotiate plan together w/ Dr knowledge and Pt needs
Determine Problem
Formulate Plan
Educate Patient
Full Hx- done on first vist or well visit VS Focused Hx- done during sick visit
Chief Complaint
Duration
Onset
Course
Characterization
Localization
Associated Features
Relieving Factors
Aggravating Factors

Past Medical Hx
Patient Concerns
Previous Evals/Pertinant Risk Factors
Summarize with Pt
Family Hx
hereditary illnesses or illnesses relevant to chief complaint
Social Hx
work, family, relationships, diet, stress, substance abuse, sexual Hx
Review of Systems
head to toe questioning to check everything
start w general
head, ENT, neck, resp, cardiac, GI, GU, musculoskeletal, skin, neuro, psych, endo/hematology

Comprehensive Physical Exam

screening
head to toe inspection for abnormalities and general wellness
respect modesty and explain what you are doing
VITAL SIGNS (HR, BP, RR, T, Pain, Pulse Ox)
97% is normal (lower end) for pulse ox in healthy adult
In Children: Head/Neck is invasive=do last!
Lungs
inspect for symmetric breathing
palpate for fremitus (when pt speaks/says 99, feel vibrations in back) or pain
fremitus increases over consolidation
fremitus decreases or is absent over a pleural effusion or pneumothorax
because sound is transmitted with less loss of intensity through a solid or fluid
percus
auscultate (bilateral sounds, crackles)
vesicular breath sounds = normal
bronchial breath sounds = abnormal (usually pneumonia)

DDx

Fremitus

Percussion

Pneumonia

increased

dull

decreased

Pleural Effusion

decreased

dull

decreased

Pneumothorax

decreased

hyperresonant

decreased

Heart
inspect
palpate (feel for apical impulse)
auscultate for rate, rhythm, norm/abnorm
aortic valve- 2nd intercostal space right of sternum
pulmonic valve- 2nd intercostal space left of sternum
tricuspid valve- 5th intercostal space left of sternum

Ausculation

mitral valve- 5th intercostal space, midclavicular line

Should make a Z

Abdomen
inspect for dilated veins (liver failure in kids), distension (hepatomegaly)
ausultate-DONT FORGET AORTA, bowel sounds, bruits aorta/renal aa
palpate- DONT FORGET AORTA, liver size, aorta, spleen, ascites, masses
percuss
Manuvers
Rebound tenderness
psoas sign
obturator sign
murphys sign
shifting dullness
Back
inspect (posture, symmetry, swelling, curvature)
palpation (tenderness in spine)
range of motion
Breast
inspect (skin change, nipple discharge, symmetry)
palpate (masses, start in axilla)
Neuro
graphesthesia
Sterognosis
consciousness, appearance, orientation, attention, concentration, language, memory, reasoning,
dementia, anxiety, depression
Genital
look for pubic hair, lesions
women: bimanual
men: scrotum/testes for masses/hernias
Tanner Staging: normal age for sexual maturity
Anorectal
external: hemorrrhoids, fissures
internal: sphincter tone, masses, prostate, occult blood in stool

Illness Script
Clinically relevant info
What you know about a disease or category of diseases
Defining and discriminating clinical features
Predisposing conditions
Pathyphysiological insult
Differential Diagnosis
A set of multiple activated illness scripts, a list of possible disease
Should include DONT MISS, MOST COMMON

Stages of DEATH and DYING denial and isolation, anger, bargaining, depression, acceptance
TRIAD OF AORTIC STENOSIS
- chest pain
- left heart failure
-exertional syncope (fainting)
JVD = indicator of Right heart failure is greater than 7cm (jugular venous distension) [ > 9cm = high atrial P
EDEMA = indicator of Right heart failure (back up in venous system)
THRILLS = indication of Left heart failure
CRACKLES = indication of Left heart failure (back up in blood returning from lungs - its like edema of the lungs)
SYSTOLIC MURMUR = indication of Left heart failure (because systole is the ventricular contraction)

DEFINING FACTOR OF LOWER AIRWAY PROBLEM = WORSE AT NIGHT Bronchiolitis or Pneumonia

(increased fremitus and crackles - get chest radiograph)
DEFINING FACTOR OF UPPER AIRWAY PROBLEM = DROOLING VS NOT DROOLING Croup (look for
steeple sign in Xray), Epiglottitis, Retropharyngeal Abcess,
if prolonged duration = Laryngimalacia
other = asthma, sepsis, anemia, myocarditis (CYANOSIS) or Congestive heart failure

ALWAYS GET A CBC IF THERE IS A FEVER OR YOU SUSPECT INFECTION

- Papilloedema = increased pressure of the ophthalmic artery (from internal carotid)
- check D DIMERS FOR PULMONARY EMBOLISM will be elevated
- tender extremity will show thrombus source
- IF YOU CAN REPRODUCE CHEST PAIN WITH TOUCH - THEN COSTOCHONDRITIS likely
- PULMONARY DISEASE CLUBBING OR CYANOSIS
- RUQ pain = usually gall bladder problem
MYOCARDIAL ISCHEMIA = radiating angina for hours, nausea, smoking/diabetes/hypertension, lung crackles
PERICARDITIS = sharp stabbing pain, worse with cough, FEELS BETTER SITTING FORWARD, JVD, friction rub
heard on auscultation,
AORTIC ANEURYSM - acute severe chest pain, uneven radial/brachial pulses, will show on chest xray
OTITIS MEDIA = loss of light reflex, fluid behind tympanic membrane, erythema of membrane
PNEUMONIA = bronchial breath sounds, egophony

FROM SPM CUTOUTS

previously healthy male, lab tests show low hematocrit (normal is 39-44%) and low MCV (normal 80-100) his iron deficiency is caused by = FORM OF BLOOD LOSS
woman who has blurred vision and at rest her eye is rotated laterally and inferiorly = CN III palsy

65 yo with fever, chills, cough, crackles in right mid ax line, chest xray indicates infiltrate obscuring right heart
border = RIGHT MIDLOBE PNEUMONIA
25 y with cough, rusty sputum, chills, fever, crackles and consolidationsigns in right axilla = RIGHT MIDDLE
LOBE PNEUMONIA
41 yo male works in warehouse, lower back pain, radiates from lower back across buttock, thigh, leg, to
ankle, weakness, no trauma, has tenderness over lumbar spine, weakness in plantarflexion and standing on
toes, with diminished ankle jerk reflex, = LUMBAR HERNIATION AT L5-S1 (pinches S1 - loss of
plantarflexion)
29 yo male - sever abdom pain in RLQ, pain on right even when palpating the left, rebound tenderness =
PERITONITIS
papilledema a sign for hypertension
70 yo female with history of breast cancer presents with shortness of breath for 2 weeks, progressive and
worse with exertion, lung exam has fremitus and dullness to percussion, diminished breath sound at T5 level,
= PLEURAL EFFUSION OF RIGHT LOWER LOBE

CONFIDENTIALITY/ DUTY TO REPORT/ INFORMED CONSENT

Informed consent
physician must disclose nature of the recommended treatment
risks & benefits & likely outcome
alternative treatments, and their risks & benefits and likely outcome
When there are no medically sound alternatives, informed consent is a matter of obtaining a patients
consent to the recommendation.
Patients have the right to refuse medical treatment
Patients choice should be promoted because most interventions have both risks & benefits; outcomes are
often uncertain
process of shared decision making
physicians role is to educate, correct patients misunderstandings, and to help patients to deliberate
in addition to persuading them to accept the physicians recommend
Patients must consent to/ agree with the treatment plan
Written consent is required for invasive tests and therapies. Consent must be voluntary.
Coercion including manipulation or misrepresentation of the medical information relating to either patients
condition or to the recommended interventions is not acceptable medical practice.
Malpractice- Informed consent
a patient must show that a physician failed to inform the patient of risks that should have been
disclosed, that the patient would not have consented had the risk been discussed and that the risk
occurred and caused harm.
Patient lacks capacity to make medical decisions a surrogate or substitute decision maker should be
appointed
Patient is suffering a life threatening emergent medical condition when delaying treatment might jeopardize
health or life of the patient,
Patients have the right to waive the right to participate in the consent process.
Physician may withhold information as therapeutic privilege if physician believes that disclosure would result
in the patient becoming so emotionally distraught as to foreclose any rational decision making- a very narrow
exception and should be well documented in the patients record.

Shared decision making

Encourage patient to play an active role in making decisions- elicit patient perspective & build a
partnership with patient.
Ensure patient is informed- provide understandable information, frame issues in unbiased manner,
interpret alternatives considering patients goals, make sure patient understands
Promote patients best interest- Help patient to deliberate, make a recommendation, try to persuade
the patient and try to dissuade patient form making choice contrary to best interest.
Confidentiality not absolute.
Exceptions
reporting and warning statutes to protect third parties or patients from harm:
Warning: Partner notification , Persons at risk
Reporting & warning: Violence by psychiatric patients
Reporting: Child & Elder abuse*, Domestic violence
Patient should be told that reporting will occur. And, as practical, physicians should minimize any
harm to the patient.
five factors to consider to justify overriding the rule of confidentiality
(1)potential for harm is serious,
(2)likelihood of harm is high,
(3)no alternative for warning exists,
(4)breaching confidentiality will prevent harm,
(5)harm to patient is minimal & acceptable.
DISCLOSING ERRORS, TRUTH TELLING, RESEARCH ETHICS
Avoiding Deception and Nondisclosure
lying-always ethically wrong
disrepect pt
undermines trust and physician integrity
deception
misrepresentation
nondisclosure
Reasons for non disclosure or deception
1- to prevent serious harm to patients who might lose hope or become clinically depressed;
2-to accommodate to different cultural traditions;
3- to respect a patients right to autonomy if the patient does not want to know
Reasons against non disclosure and deception
what does the individual patient want to know notwithstanding the patients cultural background;
2- patients need information to make informed decisions;
3- disclosure of information can help patients to adhere to treatment regimes and prevent them from
imagining worse diagnoses;
4- deception requires more deception;
5-deception is impossible because another provider will inadvertently disclose.
Caveats
1- exceptions are a last resort
2- all deception if not checked is subject to slippery slope

3- continued, long term deception is subject to abuse.

Steps to avoid and to resolve ethical dilemmas relating to nondisclosure and misrepresentation:
Anticipate dilemmas by determining what patient wants (talk to patient),
Respect the patients preference, elicit and discuss concerns, try to persuade patient to choose
disclosure, minimize non disclosure of patients record.
Discuss with family when they are decision makers or do not want the medical nformation to be
disclosed to the patient.
Focus on how to tell not whether to tell,
If withholding information, plan for future contingencies, based on non disclosure
Avoid deception and non disclosure to third parties including colleagues.
When breaking bad news to patients:
Provide a calm setting
Warn the patient (I am afraid I have some bad news)
Avoid jargon (patient may misunderstand euphemisms)
Allow time for the patient to react
Keep first discussion brief
Elicit patients concerns, provide realistic hope, show concern, repeat the news
Keeping Promises
Physicians who make and keep promises to patients promote trust in the physician/ patient
relationship and may reduce the uncertainty and fear, inherent in illness,.
A promise is a commitment to act in a certain way in the future, to do something or to refrain rom
doing something.
Breaking promises to patients may violate the ethical principles of patient autonomy, cause harm to
the patient, reduce patient trust in future promises and undermine the physicians integrity and the
patients trust in the surrounding medical community and medical profession as a whole.
Physicians should instead elicit and address the patients concerns underlying the request for a
promise.
Disclosing Errors
Medical error either a failure of a plan to be completed as intended or the use of a wrong plan to
achieve an aim.
Errors can be either acts or omissions.
An adverse event is an undesired patient outcome that results from medical error and not the
underlying disease or trauma.
appropriate treatment plan carried out correctly such as drug related side effects.
Disclosure of medical errors is becoming the standard of care.
Physicians are reluctant to disclose medical errors
Physician is not responsible for the error
Physician fears the patients/ familys response to the disclosure
Reasons for disclosing errors to patients/ surrogates
Disclosure respects the patient
Disclosure benefits the patient
Disclosure benefits the physician
Disclosure may benefit the physician- patient relationship.
What should physicians say when disclosing errors?

physicians responsibility to patient over self interest should prevail.

disclose, express regret that error occurred, fully explain the error and consequences, discuss
steps that are being/ will be taken to mitigate/ prevent patients injury and suffering resulting
from the error
Near misses/ medical errors which have not caused patient harm/ adverse effects should be reported
to quality improvement departments/ programs for identification, analysis and steps to avoid
recurrence of the same error.
Physician should explain the unintended outcome.
When trainees make mistakes they should report them to a supervising physician,
Ethical responses of physicians to errors made by other physicians might include:
Ask the physician who made the error to disclose the error to the patient
Arrange a joint conference with present physician, the previous physician who made the error
and the patient/family
Disclose the error of the other physician after giving the other physician the opportunity to
disclose the error to the patient first
telling the other physician of the intent to tell the patient of the error.
Clinical Research
CORE ETHICAL CONFLICT: how to advance scientific knowledge and simultaneously protect the
well-being of the research subject.
obtain informed and voluntary consent from potential research subjects.
Beneficence requires that the research design be scientifically sound & that the risks of the research
be acceptable in relation to the anticipated benefits.
Justice requires that benefits & burdens be fairly distributed.
Federal regulations require that human research be approved by an Institutional Review Board (IRB).
When potential research subjects lack capacity to give informed consent, their surrogates, treating
physicians and the investigators assure that a research project is appropriate for participation.
Justice (fairness) requires that vulnerable populations not be used as research subjects for
convenience of the investigators.

RIGHT TO REFUSE TREATMENT/ DUTY TO TREAT/ PROFESSIONAL RESPONSIBILITY/

EXTREMECONDITIONS
Decision- Making Capacity
Physicians must respect the informed, autonomous choices of their adult patients regarding their
medical care unless the patient lacks decision making capacity.
When a patient lacks a surrogate should be appointed to assume the decision making power.
Capacity to make medical decisions is not a global determination of legal competence/ incompetence
which must be determined by a court.
Capacity to make medical decisions is specific.
standards to determine patients capacity to make medical decisions
1- Communication-patient appreciates his/ her ultimate authority to decide, is willing to choose
among alternatives and communicates the choice either verbally, in writing , by blinking or
nodding as the medical condition may dictate.

2- Understanding patient understands pertinent information: the diagnosis and prognosis, the
nature of the proposed tests/ treatments and the alternatives, the risks and benefits of those
proposed and the alternatives and appreciates the probable consequences of each.
3- Decisions are consistent with the patients values and goals.
4- Decisions are not the result of delusions.
5- Patient uses reasoning to make the choice
Mental tests for determining capacity
evaluating orientation (name, place & date) attention span, short term memory, and ability to
perform calculations
Refusal of Treatment by Competent, Informed Patients
A competent, informed adult has the legal right to refuse medical treatment
Physicians should attempt to persuade their patients to consent to recommended, beneficial care but
must ultimately respect a competent adult patients informed refusal.
The strongest refusals of care are informed, voluntary, clearly articulated, consistent with the patients
values & goals and steadfast over time.
Physician should assure that the refusal is voluntary & not coerced
1- talking with the patient alone when
2- asking whether or not the patient would accept court ordered treatment
3-clarifying refusal
4- clarifying that the reason for refusal is as stated and not for another reason / fear which
physician could address or remove.
When parents refuse necessary medical care for minor children seek review of these refusals
including seeking a court order to provide a child with the necessary medical care.
Right to refuse medical treatment restricted when a patients refusal of treatment harms other people
In cases of pregnancy, attempts to force medical treatment upon a pregnant woman for the best
interest of the fetus rejected by the courts as a violation of the womans bodily integrity and right of
self determination.
Standards for Decisions When Patients Lack Decision- Making Capacity
Advance Directives
oral to physician, family, friends
limitations: statements related to care of others not patient; statements may be casual; listener
may not accurately recall statement
written docs
living will
health care proxy
Substituted judgments- proxy decision makers chosen by the patient
Best interest Standard when patients preferences are unknown, surrogates/ physicians act in best
medical interest of patient.
Surrogate Decision Making
When a patient lacks the capacity to make medical care decisions, physicians turn to surrogates to
make decisions on the patients behalf.
Written designations are best and avoid any confusion about whom the patient wants to make
decisions.

Courts have the legal authority to declare a patient incompetent and to appoint a guardian to make
legal decisions.
Respecting each family members opinion may facilitate future family harmony.
When no family member is available physicians should consult other physicians, the hospital ethics
committee and, as a last resort, the courts.

SKILLS LAB
Lab 1 presentation notes
nosocomial infections - not present or incubating at the time of admission to the hospital
impact = 28-45 billion dollars and 99,000 deaths/year
35% of infections are preventable
risks = from IVs, catheters, ET tubes, central lines, wounds
UTI = most common (32%), Surgical Site infections or Pneumonia (15%), Blood stream infection 5%
UTI - E coli, enterococcus, candida albicans
pneumonia - staph aureus, streptococcus pneum, enterobacter
blood stream = staph aureus, E Coli, candida albicans, enterococcus
antibiotic resistance may lead to increased morbidity
RISK TO HC WORKERS blood borne (HIV(0.3%risk), Hep B (most risk after needle stick
exposure) and Hep C) and airborne (TB, Measles, Varicella)
if exposed - wash immediately and report incident
PREVENTION = wash, glove, mask, eye protection, face shield, gown WHEN IN CONTACT WITH
BLOOD OR BODY FLUIDS
AIR BORNE PRECAUTIONS: - TB, Measles, Varicella, SARS wear N-95 mask and isolate patient
in neg pressure room
CONTACT PRECAUTIONS: - MRSA or VRE, Resp syncytial virus, Scabies, Clostridium difficile
wash, glove, wash
DROPLET PRECAUTION - cough, sneeze, suction, talk = Influenza, pneumococcus, Meningitidis
place patient in private room
Risk of HIV transmission with a needle stick is 0.3-0.4%.
SKILLS LAB 2
TEMPERATURE= normal is 37 degrees Celcius, or 98.6 degrees F
oral, rectal, axillary
PULSE = normal 60-100/min [Bradycardia <60, Tachycardia >100]
temporal, carotid, brachial, radial, femoral, dorsalis pedis
paradoxical pulse = changes with respiration
RESPIRATION
adult = 12-16/min, 20-30 for children, 35-40 for infant
Tachypnea = increased rate, Bradypnea = decreased rate
BLOOD PRESSURE
Systolic (ventricular contraction) / Diastolic (recoil pressure by arterial walls)
PULSE PRESSURE = SYSTOLIC - DIASTOLIC

MEAN ARTERIAL PRESSURE = (SYSTOLIC + 2XDIASTOLIC) / 3 normal is 70-100

PAIN ASSESSMENT
mild = 1-3, moderate = 4-6, severe = 7-10

SKILLS LAB 3
- BLS straining
- for an adult compressions are 30:2 and for a small child or infant it is 15:2
- look for the rise of the chest with breaths- do compressions on lower half of breast bone
-want to give 100 beats/min
- if circ is fine and just need to administer breaths = 12-20 breaths per minute (so every 3-5 seconds)

SKILLS LAB 4
Blunt Trauma from Motor Vehicle Crash, Falls, Altercations
Penetrating Traumas from Gun shot wounds and Stabs
Common C spine injuries adults = C5-C6 and children C2-C3
Spinal cord injuries
Paraplegia (paralysis both legs), Quadriplegia (both legs and arms), Hemiplegia (arm and leg on one
side)
average age that gets spinal cord injury = 31 (range 16-30) & 82% are males
by MVC (43%) Falls (21%) Violence (18%) Sports-related (10.5%)
BRAIN INJURIES direct injuries from blunt trauma (hit in the head) and indirect injuries from lack of
oxygen (airway obstruction, decreased perfusion from hypotension)
HEMORRHAGE CONTROL
1. apply direct pressure to wound
2. elevate body part
3. pressure point
4. tourniquet (LAST RESORT)
Class I - 15% blood loss, II - 15-30%, III 30-40%, IV >40% blood loss
@ class II tachcardic with narrow pulse pressure (DIFFERENCE BETWEEN SYST AND
DIAST BP)
@ III - are hypotensive and have increased RR
@ IV - hypotensive, tachycardic still, increased RR, low organ hyperfusion
Splinting = RIgid Board, Padded Board, Air-Inflated, Traction
Post splint placement -- ASSESS pain numbness, change in color or feel cool to touch, loss of movement
**** dont forget to check ABCs during
Fracture types == closed, open, comminuted, avulsion, greenstick, torus