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NBME 21 Answers

nbme21/Block 3/Question#39 (23.7 difficulty score)
A 74-year-old woman with mild dementia is ...
Inability to understand the severity and prognosis of her medical condition🔍

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 +9  upvote downvote
submitted by drdoom(615),
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Semt lyutclaa ,etstas “On tqeunin,gosi the niattpe sdeo ton nkow het daet [met]i, hte amen of the hitopals cla[]ep, or eth enma fo rhe rsneu who hda sujt rducnioted mlhfsie p]sno[re.” S,o pt is ioesnidtrde to imte dan cepal (ihoCce ;)A atth si ieildnfyet gnroecncin -- sa uwldo be edrdeesps oodm h(oCiec E) dna het etohr occhsei -- tbu byitlinai“ to neastddnru rvseyeti nda nri”pssgoo is hte tmso nccgenrion nisce atht si hte reyv nnfiidoeit of pcayiac.t yilInaibt ot uatdesnndr = lkac of .pyaaicct

lovebug  you explain very clearly. THX!!! +  

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I iybuvloso hthtugo ttah hte amin tghni ofr ctycapia si to tddnsreuan hte erysetvi nda isrosgnop fo ehr cdlmiae dnicoonit UBT I oguthht shti wsa a ktcir squtneio escuaeb thye aksde "fi eht tnmael ieaninoxtma fnginid sh"do.e.w. nda the tmse aldfie ot teonmin hygannti aobut erh neotranitio to paecl ro iet.m ubmd

drdoom  Stem actually states, “On questioning, the patient does not know the date [time], the name of the hospital [place], or the name of her nurse who had just introduced himself [person].” So, pt *is* actually disoriented to time and place (Choice A). That is definitely concerning -- as would be depressed mood (Choice E) and the other choices -- but “inability to understand severity and prognosis” is **the most concerning** since that is the very definition of capacity. Inability to understand = lack of capacity. +  
sahusema  So by the logic of the question, if someone understands the severity of their medical condition AND happens to also be disorientated to place and time. Go ahead and do sx on them, it's fine. +1  

4 criteria must be met to know if a patient has capacity (taken from Dirty Medicine'sYouTube channel): "ICAL"

I: patient is fully INFORMED about the decision at hand (e.g. doctor tells patient you had a lung infection which worsened and spread to your blood and you become septic then you developed cardiac arrest and we had to perform CPR on you and give you epinephrine to bring yo ass back)

C: patient COMMUNICATES their decision (e.g. explicitly says "I want to be discharged")

A: patient APPRECIATES the nature and severity of the illness (e.g. doctor tells patient you might die if you leave against our medical advice and then the doctor asks the patient to repeat it back to make sure he comprehended that fact)

L: patient can explain their decision in a LOGICAL and linear fashion (e.g. patient says his dad was in an ICU before with many tubes and blood samples being drawn and was on a ventilator and the patient doesn't want to end up like his dad)

NOTE: the patient's "logical" explanation of their decision does NOT have to actually be a good medical decision. As a doctor, you can disagree with their poor medical choice, but as long as the patient came to that decision with capacity intact, then you should respect their decision (autonomy).

 +0  upvote downvote
submitted by step1soon(43),

Time, place, name → assesses orientation → to see if pt is for example intoxicated or not

Decision making capacity is based off of whether the patient understand her diagnosis and is making an informed consent → she knows and understands