Meningitis Patient Refusing Antibiotics! - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
Home
USMLE Articles
USMLE News
USMLE Polls
USMLE Books
USMLE Apps
Go Back   USMLE Forums > USMLE Step 2 CK Forum

USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam


Reply
 
Thread Tools Search this Thread Display Modes
  #1  
Old 07-12-2012
tyagee's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,365
Threads: 648
Thanked 584 Times in 354 Posts
Reputation: 594
Medicolegal and Ethics Meningitis Patient Refusing Antibiotics!

A 21-year-old college student is brought to the ER by her roommate for symptoms of headache and fever with stiff neck over the past 18 hours. On exam she is somnolent but able to be aroused, with a temp of 39 0 C (102.2 0 F), BP 100/52, P 112. Nuchal rigidity is present. The remainder of her exam is unremarkable. WBC is 24,000. The patient gives consent for a lumbar puncture. You order a stat dose of IV antibiotics, which the patient overhears; she becomes agitated and refuses the antibiotics.
You carefully explain the high risk of death from untreated meningitis. The patient continues to refuse antibiotics and is more agitated.
What should you do?
A. Treat with IV fluids only, since antibiotics carry a risk and shouldn't be given without patient consent.
B. Treat with antibiotics because the patient has a life-threatening condition.
C. Obtain a court order urgently for treatment.
D. Obtain consent from the patient's roommate and give antibiotics.
Reply With Quote Quick reply to this message



  #2  
Old 07-12-2012
K06100's Avatar
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 730
Threads: 90
Thanked 456 Times in 289 Posts
Reputation: 466
Default

A.......................
__________________
Try Not To Become A Man Of Success But A Man Of Value.
Reply With Quote Quick reply to this message
  #3  
Old 07-12-2012
USMLE Forums Scout
 
Steps History: Step 1 Only
Posts: 18
Threads: 0
Thanked 5 Times in 3 Posts
Reputation: 2
Default

Quote:
Originally Posted by K06100 View Post
A.......................
I'd say A since the patient was conscious and able to make decisions. Also wasn't an immediate threat to anyone so you can't supersede the pt wish. Really stupid rule if you ask me.
Reply With Quote Quick reply to this message
  #4  
Old 07-12-2012
USMLE Forums Master
 
Steps History: 1+CK+CS
Posts: 1,867
Threads: 149
Thanked 2,086 Times in 1,046 Posts
Reputation: 2106
Default

B. Treat with antibiotics because the patient has a life-threatening condition.
Reply With Quote Quick reply to this message
  #5  
Old 07-12-2012
tyagee's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,365
Threads: 648
Thanked 584 Times in 354 Posts
Reputation: 594
Default

Quote:
Originally Posted by Novobiocin View Post
B. Treat with antibiotics because the patient has a
life-threatening condition.
Physician can treat EMERGENT life and limb saving condition without consent from patient. Is there any emergency in this case ? I agree it is life saving but can't find the emergency part. Comments ?
Reply With Quote Quick reply to this message
  #6  
Old 07-12-2012
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 127
Threads: 3
Thanked 112 Times in 62 Posts
Reputation: 122
Default

Quote:
Originally Posted by tyagee View Post
Physician can treat EMERGENT life and limb saving condition without consent from patient. Is there any emergency in this case ? I agree it is life saving but can't find the emergency part. Comments ?
Meningitis is a medical emergency. Aggressive Abx treatment is so urgent that it should be commenced before you do an LP, even though the Abx treatment will screw up your CSF culture results.

Still, you can't treat an adult patient without consent, even in an emergency. You can treat kids without their parents' consent in an emergency, but an adult has the right to refuse life-saving treatment. Case in point: Jehovah's Witnesses and blood transfusions.

But I think this case is an exception because the patient is agitated as a result of his condition. In a patient who does not have the capacity to make decisions, you can treat them without consent in emergencies. In a non-emergency, you have to seek a court order.

This is actually a poorly-written question because it doesn't give us enough information to assess the patient's decision-making capacity. In order to have the capacity to make a decision, the patient must understand the illness, understand the treatment options, AND be able to repeat all of that information back to you in a coherent manner. You can't answer the question until you can assess those factors.
Reply With Quote Quick reply to this message
The above post was thanked by:
tyagee (07-12-2012)
  #7  
Old 07-12-2012
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 1,175
Threads: 38
Thanked 852 Times in 478 Posts
Reputation: 862
Default

A

I think pt is comprehensible, and hence the permission to do an LP was obtained. This is key to it, pt has capacity when you asked to do any LP, they dont just suddenly lose this capacity if they refuse to take Abx.
__________________
PGY-3
To view links or images in signatures your post count must be 10 or greater. You currently have 0 posts.
Reply With Quote Quick reply to this message
  #8  
Old 07-12-2012
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 127
Threads: 3
Thanked 112 Times in 62 Posts
Reputation: 122
Default

Quote:
Originally Posted by patelMD View Post
A

I think pt is comprehensible, and hence the permission to do an LP was obtained. This is key to it, pt has capacity when you asked to do any LP, they dont just suddenly lose this capacity if they refuse to take Abx.
Sure they can, if their condition has progressed and they've become agitated since the LP. The LP might even have exacerbated the agitation.

The patient being comprehensible is actually not one of the criteria for capacity to consent. For instance, if somebody has cerebellar dysarthria, you might not be able to understand what they're saying, but they can be fully capable of consenting.

I think the key here is that the patient was agitated during the discussion about Abx, but wasn't agitated during the discussion about the LP.

Again, it's a poorly-written question. Capacity assessments require much more information than this.
Reply With Quote Quick reply to this message
The above post was thanked by:
tyagee (07-12-2012)
  #9  
Old 07-12-2012
tyagee's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,365
Threads: 648
Thanked 584 Times in 354 Posts
Reputation: 594
Default

Quote:
Originally Posted by shan564 View Post
I think the key here is that the patient was agitated during the discussion about Abx, but wasn't agitated during the discussion about the LP.
yup. in expln part of this q, its written in similar way.

that means this patient needs treatment because it is emergency and he has lost decision making capacity.right ?

btw, there was question in which patient developed meningitis and was competent too. but still ans was to treat with antibiotics against his wishes . in that , patient was having N meningitidis and qbank expln said to treat because it is transmissible and can do harm in community. rem? it was from uworld i guess.
Reply With Quote Quick reply to this message
  #10  
Old 07-12-2012
XpaezX's Avatar
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 1,216
Threads: 41
Thanked 1,316 Times in 706 Posts
Reputation: 1331
Default

Answer is b , meningitis is and emergent condition and you dont need patients permission, also she became agitated when she heard aboutthe use of antibiotics but not of an invasive procedure.. Are you serious? What a weird question and scenario
Reply With Quote Quick reply to this message
  #11  
Old 07-13-2012
USMLE Forums Scout
 
Steps History: 1 + CS
Posts: 53
Threads: 10
Thanked 22 Times in 19 Posts
Reputation: 32
Default

The ans is B.
And Right you are tyagee!
The Q you are refered to is from UW and also has the tiny details of this being one of the rare cases where although the pt. is coherent and competence although questionable, can't be determined to be lost, but inspite of that, Her condtn points towards an infecn of N. meningitidis (clue dorm room) which is not only a threat to herself but also to those around her, The only options are:
1) Rx the pt with antibiotics (Preferably)
2) and last resort - incarceration of the pt. ( and since this option isn't given, Our job has been made easier)
Reply With Quote Quick reply to this message
  #12  
Old 07-13-2012
tyagee's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,365
Threads: 648
Thanked 584 Times in 354 Posts
Reputation: 594
Default

Okay. Let's have twist here

Had the patient refused to both LP and antibiotics , then what would be the answer ? It's emergent situation but patient says No to all interventions. And patient though agitated appears competent.

Please reply.


Sent from my iPhone using Tapatalk
Reply With Quote Quick reply to this message
  #13  
Old 07-13-2012
USMLE Forums Scout
 
Steps History: Not yet
Posts: 61
Threads: 7
Thanked 81 Times in 32 Posts
Reputation: 91
Default

Quote:
Originally Posted by tyagee View Post
Okay. Let's have twist here

Had the patient refused to both LP and antibiotics , then what would be the answer ? It's emergent situation but patient says No to all interventions. And patient though agitated appears competent.

Please reply.


Sent from my iPhone using Tapatalk
Do not mess with the patient if he is competent.
As far as i know doctors can manage the patient the way they want only upto 18 yrs of age. Beyond that patient consent is absolutely essential.
Also 'suicidal' patients are considered incompetent.
However this patient although agitated, is competent, so do not do LP.
Reply With Quote Quick reply to this message
The above post was thanked by:
tyagee (07-14-2012)
  #14  
Old 07-13-2012
usmledee's Avatar
USMLE Forums Veteran
 
Steps History: 1+CK+CS
Posts: 257
Threads: 69
Thanked 122 Times in 63 Posts
Reputation: 132
Default

Quote:
Originally Posted by tyagee View Post
Okay. Let's have twist here

Had the patient refused to both LP and antibiotics , then what would be the answer ? It's emergent situation but patient says No to all interventions. And patient though agitated appears competent.

Please reply.


Sent from my iPhone using Tapatalk
For the first scenario..I would go with treating the pt because it may be a communicable disease...

The second scenario however..without an LP..you can't confirm it's meningitis and in that case you really can't hold the pt, in my opinion. So no Dx if the pt doesn't consent to it..but once you have a Dx ..then I think she must be treated if it is a communicable disease..but i believe you would have to have that documented for you to treat without consent.

So what's the consensus on this?
Reply With Quote Quick reply to this message
  #15  
Old 07-13-2012
XpaezX's Avatar
USMLE Forums Master
 
Steps History: 1+CK+CS+3
Posts: 1,216
Threads: 41
Thanked 1,316 Times in 706 Posts
Reputation: 1331
Default

I would still incarcerate her and give antibiotics, she is a biological threat, i could care less about any law,she is going down.
Reply With Quote Quick reply to this message



  #16  
Old 07-13-2012
usmledee's Avatar
USMLE Forums Veteran
 
Steps History: 1+CK+CS
Posts: 257
Threads: 69
Thanked 122 Times in 63 Posts
Reputation: 132
Default

Quote:
Originally Posted by XpaezX View Post
I would still incarcerate her and give antibiotics, she is a biological threat, i could care less about any law,she is going down.
.....well at least one of us has finally made up their mind
Reply With Quote Quick reply to this message
The above post was thanked by:
XpaezX (07-14-2012)
  #17  
Old 07-14-2012
USMLE Forums Scout
 
Steps History: 1 + CS
Posts: 53
Threads: 10
Thanked 22 Times in 19 Posts
Reputation: 32
Default

@ tyagee:
since there's a twist, please be so kind as to give us the "new options" , to our luck, this is an MCQ test.
As far as 'free world objective answeres' are concerned, I feel incarceration is still warranted based on the circumstantial evidence of :
1) college dorm student
2) fever &
3) nuchal rigidity
and while i'm at it let me add prophylaxis(Rifampin) for the roomie!

BTW I don't mean to shoot down this interesting conversation down but IMHO there is a reason why the ppl on the board spend hours framing a question, There has to be ONE ABSOLUTE correct answer.
Reply With Quote Quick reply to this message
The above post was thanked by:
XpaezX (07-14-2012)
  #18  
Old 07-14-2012
usmledee's Avatar
USMLE Forums Veteran
 
Steps History: 1+CK+CS
Posts: 257
Threads: 69
Thanked 122 Times in 63 Posts
Reputation: 132
Default

What.is.the.answer?
Reply With Quote Quick reply to this message
  #19  
Old 07-14-2012
tyagee's Avatar
USMLE Forums Master
 
Steps History: ---
Posts: 1,365
Threads: 648
Thanked 584 Times in 354 Posts
Reputation: 594
Default

Quote:
Originally Posted by tyagee View Post
A 21-year-old college student is brought to the ER by her roommate for symptoms of headache and fever with stiff neck over the past 18 hours. On exam she is somnolent but able to be aroused, with a temp of 39 0 C (102.2 0 F), BP 100/52, P 112. Nuchal rigidity is present. The remainder of her exam is unremarkable. WBC is 24,000. The patient gives consent for a lumbar puncture. You order a stat dose of IV antibiotics, which the patient overhears; she becomes agitated and refuses the antibiotics.
You carefully explain the high risk of death from untreated meningitis. The patient continues to refuse antibiotics and is more agitated.
What should you do?
A. Treat with IV fluids only, since antibiotics carry a risk and shouldn't be given without patient consent.
B. Treat with antibiotics because the patient has a life-threatening condition.
C. Obtain a court order urgently for treatment.
D. Obtain consent from the patient's roommate and give antibiotics.
ans to this q is B.
Reason
1. its emergency and patient "suggestive" of features of incompetence [ agitated, saying yes to invasive procedure and no to antibiotics ]

btw, regarding what patient had said no to both lp and antibiotics, i dont knw the ans .
i think board guys will make us choose to incarcerate by giving clues to N meningitidis which is community threat.

hope its making sense...
Reply With Quote Quick reply to this message



Reply

Tags
MedicoLegal-Ethics, Step-2-Questions

Quick Reply
Message:
Options

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Location
Where you live. Leave blank if you don't want to tell.

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes


Similar Threads
Thread Thread Starter Forum Replies Last Post
Child with Meningitis; Antibiotics or CT or LP? tyagee USMLE Step 2 CK Forum 5 05-25-2012 03:21 PM
Parents refused antibiotics for their child with meningitis! USMLE-Syndrome USMLE Step 1 Forum 32 01-26-2012 10:14 PM
Meningitis in an alcoholic patient? aksyonez USMLE Step 2 CK Forum 2 06-21-2011 03:36 PM
Meningitis and Pneumonia Microorganims by Age of patient! lookingup USMLE Step 2 CK Forum 1 05-17-2011 08:29 AM
Refusing Blood Transfusions? Hohepa USMLE Step 2 CK Forum 2 04-15-2010 02:43 PM

RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2017 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)