Communication and Professionalism 1

An 81-year-old man with mild dementia (MMSE 24/30) is admitted for management of a large gastric ulcer with active bleeding. The surgical team recommends urgent endoscopy with possible intervention. When you explain the procedure and its risks, benefits, and alternatives, he repeats back the key information in his own words, explains why the procedure is being recommended, and states he understands he could decline and what might happen if he does — but he becomes intermittently confused about the date and location. His daughter, who is not his substitute decision-maker, asks you to 'just do the procedure, he's confused, I'll sign for him.'

A 3-month-old boy is brought to the emergency department by his father because he has cried constantly and has not moved his left arm since this morning. The father states that the baby was "bounced on my knee" 2 days ago and the arm "looked fine until today". The infant was born at term, has no previous illnesses, and takes no medications. On examination he is irritable but consolable, with a tender swollen left mid-upper arm that he does not move, a 2-cm bruise on the left ear pinna, and two small bruises on the abdomen. The remainder of the examination is normal. The mother is at work and the father is the only caregiver present.

A 34-year-old woman presents to the emergency department after a fall down the stairs at home. She has tenderness over the left wrist and bruises on both upper arms, some purple and some yellow-green. Her partner stays at the bedside, answers most questions for her, and says she is "clumsy". She avoids eye contact and gives short answers. She takes no medications and has no known allergies. Wrist radiograph shows no fracture.

A 19-year-old woman presents to a family medicine clinic with persistent facial, chest, and back lesions that have caused scarring and significant distress. Despite 4 months of adapalene-benzoyl peroxide topical gel and a 12-week course of doxycycline PO, which she completed 1 month ago, she continues to develop new lesions. On examination, there are multiple inflammatory papules, pustules, and deep nodules on the face, chest, and upper back, with several pitted and pigmented scars. She has no past medical history, takes no other medications, and has no allergies. She is sexually active with a male partner, uses condoms inconsistently, and does not use other contraception. A urine pregnancy test today is negative.

A 24-year-old man is brought to the emergency department by police after threatening his neighbours. He is pacing, shouting, and clenching his fists, and he tells staff to stay away from him. He has a history of schizophrenia and stopped his olanzapine 3 months ago. He has no known allergies and no history of head injury. Capillary glucose is 5.4 mmol/L, and there are no focal neurological findings or obvious injuries.

A 32-year-old man is brought to the emergency department by his sister because he has been shouting at neighbours and has not slept for 3 days. He has a history of schizophrenia and stopped his antipsychotic 2 months ago. He has no other medical conditions and no known allergies. In the triage room he is pacing, speaking loudly, and clenching his fists, and he says that staff are "sending signals" about him. Capillary glucose is 5.6 mmol/L (4.0-7.8), and he has no signs of head injury or intoxication. You are about to assess him.

A 24-year-old woman presents to a community clinic for her first visit 3 weeks after arriving in Canada as a government-assisted refugee from Somalia, following 6 years in a refugee camp in Kenya. She speaks Somali and very little English and is accompanied by her husband, who answers most questions on her behalf. She reports fatigue and painful menses; she takes no medications, has no known allergies, and has no immunization records. On examination, she is thin with mild conjunctival pallor and is quiet, avoiding eye contact. BMI is 18.5 kg/m2.

A 74-year-old man with atrial fibrillation, taking warfarin with a stable INR of 2.4 for 2 years, presents to the emergency department with a 6-hour nosebleed and new bruising on both forearms. Five days ago you treated him in your clinic for a urinary tract infection with trimethoprim-sulfamethoxazole, and you did not adjust his warfarin plan or arrange an INR recheck. The epistaxis has stopped with anterior nasal packing, and he has no other bleeding. Hemoglobin is 118 g/L (130-170) and INR is 7.2 (2.0-3.0). You realize that you missed a major drug interaction.

A 34-year-old man, new to your walk-in clinic, presents with 2 days of low back pain after lifting boxes during a move. He rates the pain 4/10, with no radiation, numbness, weakness, bladder or bowel dysfunction, fever, or history of trauma or cancer. He takes no medications, has no allergies, and has no history of gastrointestinal bleeding, renal disease, or hypertension. On examination, he walks comfortably, has paraspinal muscle tenderness, and has a normal neurological examination of the lower limbs. He tells you, "I need morphine, it's the only thing that works for me."

A 74-year-old man with type 2 diabetes is admitted to hospital with community-acquired pneumonia. Overnight, a nurse finds him diaphoretic and confused with a capillary glucose of 2.2 mmol/L (4.0-7.8). He is treated with IV dextrose and recovers fully, and his glucose is now 8.6 mmol/L. On reviewing the medication administration record the next morning, you, the attending physician, find that you entered a second insulin glargine order while updating his admission orders, and he received twice his usual bedtime dose. No one else has recognized this. The patient is alert and asks you why his sugar dropped.

A 38-year-old man presents to a walk-in clinic with 2 days of low back pain that began after he lifted heavy boxes while moving. He rates the pain 5/10, it does not radiate to the legs, and he walked into the room without difficulty. He has no fever, weight loss, trauma, urinary retention, or saddle numbness. On examination, there is paraspinal muscle tenderness and reduced forward flexion; straight leg raise is negative and lower limb neurological examination is normal. He has no chronic medical conditions, takes no regular medications, and has no known allergies, renal disease, or history of gastrointestinal bleeding. He tells you that he "only needs morphine" because it is the one thing that works for him.

A 28-year-old woman presents to a family medicine clinic for a first health assessment 3 weeks after arriving in Canada as a refugee from Somalia, where she lived for several years in a refugee camp. She speaks only Somali and is accompanied by her husband, who offers to interpret, and her 4-year-old daughter. She reports fatigue, painful menses, and a slow urinary stream with two urinary tract infections in the past year. She has no immunization records, takes no medications, and has no known allergies. On examination she appears thin and pale, and genital examination shows scar tissue covering the vaginal introitus with a pinhole opening. Hemoglobin is 98 g/L (120-160), MCV 72 fL (80-100), and eosinophils are 1.2 x 10^9/L (0.0-0.5); urine hCG is negative.

A 76-year-old man is on postoperative day 2 after right hip hemiarthroplasty for a femoral neck fracture. At 0200 the nurse calls you because he is shouting that staff are trying to harm him, is trying to climb out of bed, and has pulled out his peripheral IV. Before surgery he lived alone, was fully independent, and had no known cognitive impairment. His medications include acetaminophen, enoxaparin, and hydromorphone PO as needed; he was given diphenhydramine PO at bedtime for sleep last night. On examination he is not oriented to place, attention fluctuates, and he has not struck anyone. Capillary glucose is 6.1 mmol/L (3.9-7.8).

An 84-year-old woman is admitted from a long-term care home with fever and increased work of breathing. This is her third aspiration pneumonia in 4 months. She has advanced Alzheimer dementia, is non-verbal and bed-bound, and has lost 8 kg over the past year with coughing during most meals. A chest x-ray shows a new right lower lobe infiltrate and she is started on antibiotics. Her daughter, who is her legally appointed power of attorney for personal care, asks for a feeding tube because "she is starving." Her only other history is hypertension and no medication allergies.

A 71-year-old man is brought to the emergency department by his wife with 2 days of worsening dyspnea and increasing drowsiness. He has GOLD grade 4 COPD, uses home oxygen, has had 3 hospital admissions this year for exacerbations, and has a BMI of 17 kg/m². He takes inhaled triple therapy (LAMA/LABA/ICS) and has no known drug allergies. His wife reports that he once told his family physician he "never wants to die on a ventilator", but he has no written advance directive. On examination he is drowsy but rousable, uses accessory muscles, and has diffuse expiratory wheezing. Arterial blood gas on 2 L/min by nasal prongs shows pH 7.24 (7.35-7.45), PaCO2 82 mm Hg (35-45), PaO2 58 mm Hg (80-100) and bicarbonate 34 mmol/L (22-26). Chest radiograph shows hyperinflation without consolidation.