In which of the following foods does botulism occur more commonly?
Correct Answer B:
Botulism is neuromuscular poisoning from Clostridium botulinum toxin. Symptoms are weakness and paralysis. Diagnosis is clinical and with laboratory identification of toxin. Treatment is with support and antitoxin.
Home-canned foods are the most common sources, but commercially prepared foods have been implicated in about 10% of outbreaks. Vegetables, fish, fruits, and condiments are the most common vehicles, but beef, milk products, pork, poultry, and other foods have been involved.
C. botulinum spores are highly heat-resistant and may survive boiling for several hours at 100° C. However, exposure to moist heat at 120° C for 30 min kills the spores. Toxins, on the other hand, are readily destroyed by heat, and cooking food at 80° C for 30 min safeguards against botulism.
A woman who is 33 weeks pregnant, complains of shoulder, neck, back and abdominal pain and denies any recent trauma.
She later discloses that her husband is an alcohol addict.
What is important to assess during your interview?
Correct Answer A:
Studies have estimated the prevalence of physical abuse during pregnancy to be about 6%. In addition, 64% of the abused women reported increased abuse during pregnancy. When a pregnant woman presents with multiple somatic complaints and has a risk factor for domestic abuse, such as an alcoholic spouse, it is important to assess for this during your interview.
A 44-year-old housewife and mother of four children (ages 6 to 13 years) has been coming to you for management of tension headaches that have not improved with trials of several appropriate medications. She has been married to a police officer for the past six years. You ask if she has been under extra stress, and she begins to cry. You notice bruises on her arms. On further questioning, you learn that her husband hits her whenever he is drunk, which is at least two nights per week. Her husband is also a patient of yours.
Which of the following is the most appropriate intervention?
Correct Answer D:
In this case the physician must act as an advocate for this woman. The question clearly describes evidence of physical abuse and an ongoing risk of possible physical harm from this husband. In this regard the physician should refer the patient to a battered women’s program much in the same way that a pediatrician would contact the bureau of child welfare if he suspected child abuse. Choices a), c) and e) offer logistical advice that do not directly address protection of the woman. Contacting her husband’s supervisor would violate confidentiality. Although both the husband and wife may be patients of this physician, the woman is clearly the individual who is at ongoing risk.
The advance directive specifications contained in an individual’s living will become effective:
Correct Answer E:
The living will, a written advance directive, allows a competent person to indicate his or her health care preferences while cognitively and physically healthy. A living will may list medical interventions the patient would prefer to have withheld or withdrawn when he or she becomes unable to communicate.
A 72-year-old male is brought by ambulance to the emergency department with weakness and numbness of his left side that began earlier this morning. While in the emergency department he becomes comatose with infrequent, gasping breaths and is quickly intubated and placed on a ventilator. A full evaluation shows an acute ischemic right sided stroke. His wife states that she wishes to have the ventilator stopped, as she believes this would be consistent with her husband’s wishes in this circumstance. She understands that this would precipitate the patient’s death. The wife presents a legally valid advance directive confirming her as the patient’s healthcare proxy.
Which one of the following responses to the wife’s request is most ethically appropriate?
Competent adult patients have the right to refuse any medical intervention, even if forgoing this treatment may result in their death. Legally and ethically it does not matter whether the patient requests that care be withheld before it is started or that it be withdrawn once it is begun. All states currently allow competent patients to legally designate a health-care proxy to make these decisions for them if they become unable to communicate or are no longer competent to decide for themselves. The patient in this example has instituted such a legal advance directive and his proxy’s request should be respected as his own and the care withdrawn. If there were no advance directive the decision in this case would become more difficult, and might require a family conference or the involvement of an ethics committee. A patient’s condition does not need to be terminal or irreversible to allow the removal of life-sustaining therapy. Legal involvement is rarely required in situations where advance directives are already available and valid.
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