Question of the Week #481

A 90 year old man with history of advanced dementia is brought to hospital with aspiration pneumonia. This is his 5th episode of Aspiration pneumonia in the past 1 year. He is accompanied by his daughter who also happens to be his healthcare proxy. She wants to focus on her father’s comfort as the goal of care and requests no further diagnostic interventions and she would like to avoid further hospitalizations. She wants to know what would make him eligible to receive hospice care. Based on which of the following factors, can he be qualified for hospice?

A. His advanced age

B. Diagnosis of advanced dementia

C. Prognosis

D. His wishes to die at home

Question of the Week # 385

385)  A 74 year old man with advanced dementia is sent from nursing for evaluation of umbilical hernia. He is accompanied by his sister who thought that the bulge looked ” ugly” and demanded that he be evaluated for surgery.  The patient has been nursing home bound for the past four years. There is no history of nausea or vomiting. When fed, he eats normally. The patient is not oriented and is unable to give further history. He does not have living will or a power of attorney. On examination, his vitals are stable. He appears comfortable. Abdominal examination showed a palpable bulge in the umbilical area which is reducible. There is no erythema and the patient winces when pressure is applied. There is no rigidity. When tried to explain him about possible surgery, the patient does not comprehend. He is not oriented to place, person or time. Which of the following is the most appropriate action at this time?

A) Do not consent for surgery

B) Obtain Psychiatry evaluation for Capacity assessment

C) Re-Evaluate his competence to make decisions

D) Consent him for surgery

E) Obtain Consent from his sister

Question of the Week # 169

169) A 77 year old woman is brought by her son for evaluation in your office for excessive forgetfulness.  Her son discovered that the patient has become increasingly forgetful over the last two years. She has difficulty managing her finances. She lives alone, drives her own car and prepares her own meals. As per son, several recent new dents were noted on her mother’s car. She is dressed well and is comfortable. Visual acuity on examination is 20/100 in both eyes and is partially corrected with glasses. She also has a fixed visual field deficit that is persistent for past one year due to a cerebrovascular accident. Rest of the physical including sensory and motor functions are grossly normal. She scores 25/30 on Mini-Mental Status examination.

The most appropriate recommendation regarding her driving at this time:

A)           Limit driving to day-time only

B)            Unrestricted driving

C)            Complete cessation of driving

D)           On-Road performance based driving test

E)            Adaptive devices for safe driving

Question of the Week # 168

168) A 70 year old woman with history of Hypertension, Diabetes mellitus, severe osteoarthritis and Macular degeneration is seen during a follow-up visit. He was seen a month ago in your office for evaluation of his driving capacity. At that time, he was noted to have significant impairment of vision and motor skills. His visual impairment persisted despite corrective glasses. He also uses cane to walk and has persistent deficits of left sided weakness and hemi spatial inattention secondary to a stroke 8 months ago. He was subsequently referred to driving rehabilitation specialist and was deemed unsafe to drive. During his visit 2 weeks ago, he has been counseled and was instructed to stop driving. While talking him about his transportation, he tells you that he drove himself to the clinic today.

Your most appropriate response at this time:

a) “When do you think it’s an appropriate time for a person to stop driving?”

b)  Let’s talk about some of your concerns regarding retiring from driving

c) I am wondering, is there someone whom you trust, and who would tell you when they thought it was unsafe for you to continue driving?

d) “You are a threat to others while driving on the road”

e) “I have a duty to protect you and so, I will have to report you to DMV”

f) “Let me refer you to Driving Rehabilitation so that they can help you with adaptive devices”

Question of the Week # 167

167)  A 77 year old woman is brought by her son for evaluation in your office for excessive forgetfulness.  Her son discovered that the patient has become increasingly forgetful over the last two years. She has difficulty managing her finances. She lives alone, drives her own car and prepares her own meals. As per her son, several recent new dents were noted on her mother’s car. She is dressed well and is comfortable. Visual acuity on examination is 20/40 in both eyes. She has seen her ophthalmologist recently and was prescribed corrective glasses which correct her vision to normal. She is compliant with using her glasses during driving. Rest of the physical including sensory and motor functions are grossly normal. She scores 25/30 on Mini-Mental Status examination.

The most appropriate recommendation regarding her driving at this time:

A)     Limit driving to day-time only

B)      Unrestricted driving

C)      Complete cessation of driving

D)     Referral to Driving Rehabilitation Service

E)     Start therapy for Alzheimer’s

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