95. A 25-year old female medical student or resident noticed a mistake made by a junior attending

physician during rounds. She is afraid of that attending physician. What is the appropriate way

to handle the situation? (Important)
Answer: She should discuss the situation with a more senior attending physician for appropriate

interpretation, advice, and assistance.

96. A 26-year old male medical student or resident made a mistake during patient care. He is

afraid of what might result. What is the appropriate way to handle the situation?
Answer: He should disclose the mistake to the attending physician and try to learn from that

mistake. The patient should be notified as well.

97. A 63-year old female health care worker is concerned about taking care of patients with HIV

infection or multidrug-resistant tuberculosis. What is the appropriate way to handle the

situation? (Important)
Answer: The physician should provide appropriate care to patients despite personal risk.

Institutions should reduce the risk of infection by appropriate equipment, supervision, and

training. Her concern should be taken seriously.

98. A 30-year old male physician has an opportunity for financial incentive if he sees more

patients and refers them unnecessarily. What is you opinion about this?
Answer: The physician should provide only care that is in the patient’s best interest.

99. Two physicians are discussing a case inside the elevator of a hospital. What is your opinion

about this?
Answer: They should not do that because they have to maintain the patient’s confidentiality.

100. The patient’s confidentiality should be maintained except in the following situations:
Physicians should override third parties in case of domestic violence, child abuse, elderly

abuse, gunshot wounds, syphilis, and tuberculosis. They should report these cases to appropriate

governmental authorities.

101. A physician is experiencing a very difficult ethical issue regarding a complicated case. He

is confused. What should be the next step?
Answer: he should discuss the matter with other faculty members in his health care team,

colleagues, or hospital ethics committee.

102. What is the final plan of action in an ethical issue?
Answer: Both patient and physician should agree regarding final management. The patient should be

well-informed about the medical condition. The physician should be sympathetic and knowledgeable

regarding the relevant medical condition.

103. DNR (do not resuscitate) order. This is appropriate if the patient or surrogate signed that

order or if CPR (cardiopulmonary resuscitation) would be futile. Physicians should write DNR

orders and the reason for them in the chart. Please remember, “slow” or “show” codes are not

acceptable. Foods and fluids are considered therapies that should be stopped. (Important)

104. (A)Brain death (adult): (Important)
(i) Definition by the President’s Committee:
Death is an irreversible cessation of circulation and respiratory functions or irreversible

cessation of all functions of the entire brain and brain stem.
(ii) The criteria of brain death by the staff of Massachusetts General Hospital and the Harvard

Committee:
Death occurs when there is absence of all signs of receptivity, responsivity, and all brainstem

reflexes, and the EEG is isoelectric. Sometimes metabolic disorders and intoxications may mimic

the above findings.
(iii) The guidelines of brain death:
(a) The diagnosis should be made also by another physician and confirmed by clinical findings and

EEG.
(b) The family should be notified. They should not make the decision about discontinuing medical

treatment except in a situation where the patient has directed the family to make the decision.
(c) The physician should discuss with another physician before removing supportive measures

(e.g., ventilators).
(d) Family members may request organ donation, and in many states physicians may request the

family to make an organ donation.
(B) Brain death (children):
(i) Definition: same as in adults.
(ii) Criteria: similar in children and adults, but the period of observation is longer in

children.
Children 1wk-2mo of age: two separate examinations 48 hours apart
Children 2mo-1yr of age: two separate examinations 24 hours apart
Children more than 1 yr of age: two separate examinations 12 hours apart
Spontaneous movements must be absent, with the exception of spinal cord reflex withdrawal and

myocolnus.
Generalized flaccidity should be present. The presence of clinical criteria for 2 days in term

and 3 days in preterm infants indicates brain death in majority of asphyxiated newborns. The

absence of cerebral blood flow on radionuclide scan and silence of electrical activity on EEG are

not always observed in brain-dead newborns. There is no universal consensus about the definition

of neonatal brain death. The decision is made after discussion with the family and health care

team. If there is difference of opinion, the ethics committee should be consulted. The decision

is made on the basis of what is in the best interest of the infants and children.

105. Practice guidelines for physicians:
(i) The best way to practice medicine is to select useful diagnostic techniques and therapeutic

measures which are most appropriate to a particular patient and clinical condition.
(ii) Practice guidelines can reduce the health care costs, which improves health care to patients

who even do not have adequate health care benefits.
(iii) Please remember, guidelines do not and should not be the only way of managing an individual

patient.

106. Some important points about patients:
(i) For a patient with an incurable disease, the major goal of therapy should be the enhancement

of the quality of life.
(ii) The patient care begins with a personal relationship between the patient and the physician.

If a patient has confidence on the physician, reassurance may be the best therapy. The patient

must understand that the physician is giving the best possible care available.

107. Patients who do not have decision-making capacity about their medical care:
The patients who do not have decision-making capacity usually arrange for surrogates who make

decisions for them. Their choices depend on their values. Psychiatrists are helpful in mentally

impaired patients. Family members are usually the surrogates, because they know the patients very

well
Advanced directives: statements made in advance in case patients lose their decision-making

capacity in the future. These directives indicate the names of surrogates and which interventions

are acceptable or not acceptable to them. These are achieved by oral conversation (most common

form), living will, health care power of attorney, or physicians can ask the patient in advance.
Absence of advance directives and surrogates: physicians can make the decision using all

information and should respect the patient’s values. Physicians must know the laws of the state

in which they practice.
Patient preferences are known:
The decision is made with the patient’s best interest in mind.
Disagreements between potential surrogates or between the physician and surrogate: Physicians can

consult with the hospital ethics committee or with other physicians. The courts should be only

the last resort.

108. Down syndrome with different medical conditions: (Very Important)
(a) Duodenal atresia at birth: surgical repair is recommended as it is done regularly.
(b) VSD (ventricular septal defect) in newborn period: initial conservative medicals management

is followed by surgical repair as it is done regularly.
(c) Cyanotic heart disease at birth: immediate medical management, which is followed by surgical

repair as it is required routinely.
(d) Cosmetic surgical condition (e.g., rhinophyma or big nose): there is no urgency to repair the

underlying condition, but it can be done as it is performed regularly.
(e) Neural tube defects (e.g., meningomyelocele): surgical repair is recommended as it is done

regularly.
Please remember, a patient’s management should be discussed with his/her parents and the decision

made with the best interest of the patient in mind.

109. A healthy male patient with Down Syndrome lives independently. He went to a doctor for

facial cosmetic surgery. Can he make his own decision? (Important)
Answer: yes. The patient can make his decision if he understands the procedure and the

consequences. He lives independently which indicates that he is capable of making his own

decision.

110. A patient went to the doctor due to throat pain. The doctor asked the patient what her

problem was. The patient said that she woke up at six o’clock in the morning, went to the

bathroom, ate breakfast, and went to drop her children at school. She then came back home, stared

cooking and continues to talk about irrelevant things. What should the doctor do to stop the

patient from rambling? (Important)
Answer: the doctor should ask the patient to tell him what problems she has related only to her

throat.

111. A patient went to a doctor for abdominal pain but remained quiet throughout the visit. He

did not tell the doctor enough about his symptoms. What should the doctor do? (Important)
Answer: the doctor must ask the patient detailed questions about his abdominal pain. It is the

doctor’s obligation to find out as much as he can about the patient. Without enough information,

the doctor will not be able to make an accurate diagnosis.

112. A patient walked into his doctor’s office with acute abdominal pain. He has been suffering

from ulcerative colitis. The patient is noncompliant and did not visit for the past six months.

What should the doctor do in this situation? (Very Important)
Answer: The doctor should find out more about the patient’s abdominal pain before making any

other decision. The doctor should always be responsible with the patients.

113. A terminally ill pancreatic cancer patient with multiple metastasis is admitted to the

hospital.
He is in critical condition. The patient wants to know his prognosis. What should the doctor say?
Answer: the doctor should tell the patient politely that he will discuss his condition with him

The doctor should never specify the longevity of the patient. The doctor should tell the truth

even when the patient is a child. The doctor should not hide any medical information from the

patient.

114. A patient is recently diagnosed with cancer. He is nervous but is eager to know about his

medical diagnosis. What should the doctor’s reply be? (Important)
Answer: the doctor should gently tell the patient his condition.

115. A patient is recently diagnosed with cancer. Previously, he had an episode of a nervous

breakdown after hearing a family death and had to be admitted to a hospital. He loves his family

members and tends to be very open with them on all issues. How should the doctor tell the patient

about his current state? (Important)
Answer: the doctor should call his family members and discuss the patient’s medical condition

openly and politely.(WRONG IF DISCLOSING BAD NEWS CLEARLY PUTS PT IN NERVOUS BREAKDOWN CONDITION

WAIT AND GRADUALLY TELL THE PT.NEVER BREAK CONFIDENTIALETY)

116. A male patient was admitted with severe myocardial infarction. He was admitted to the ICU

and his condition is very critical. He does not know the reason for his admission. The patient is

unstable. What should the doctor tell the patient? (Important)
Answer: the doctor should wait until the patient is stabilized and then gently tell him his

medical condition.(HIDING SOMETHING FROM THE PT MAKES HIM MORE SUSPICIOUS AND MAY LEAD TO ALL

KIND OF MISCONCEPTION IN PTS MIND SO NEVER WAIT TO TELL PT UNLESS TELLING IS CLEARLY DETREMENTAL)

117. A mother gave birth to a premature baby who was admitted to the NICU (neonatal intensive

care unit). The baby is on a mechanical ventilator. The mother wants to hold the baby IN HER

ARMS. What should the doctor do in this situation? (Important)
Answer: the mother should be allowed to hold the baby.

118. A male patient is recently diagnosed with HIV. Should the doctor ask about his sexual

orientation (i.e., male, female, or both)? (Important)
Answer: yes, the doctor should ask the patient directly but politely about his sexual

orientation.

119. A homosexual male patient went to a doctor. The patient’s partner was recently diagnosed

with HIV. Should the doctor ask the patient whether he is being penetrated by his partner or he

penetrates his partner?
Answer: yes, because the person who is being penetrated has a higher incidence of HIV due to

trauma in perianal area.

120. A 6-year old boy comes to the ER after drowning. He expired in the ER despite appropriate

resuscitations. The family members became angry which is a reflection of a sense if guilt and

helplessness. What is the appropriate way of giving information to the family members?
Answer: the physician should give the information clearly and compassionately when there is no

hope for survival. Parents need to know that everything was done to save the child.

121. A pregnant woman who is Rh(-)ve became sensitized. She had H/O induced abortions. Her

husband is not aware of his wife’s previous abortions. He wants to know from the physician how

she became sensitized. (Very Important)
Answer: the physician should tell the man to ask his wife. The physician should not mention

anything about the patient’s H/O abortions.

122. A mother brought her infant to the ER. The radiologist test reveals old fractures of the

ribs. She did not know anything about that. (Very Important)
Answer: this is a case of child abuse. This case should be reported to child welfare agency.

123. A physician is examining a child with respiratory distress. The child’s mother became

anxious during the physical examination. Please remember, a patient’s management should be

discussed with his/her parents and the decision made with the best interest of the patient in

mind. (Important)
Answer: child abuse.( ICUDNT UNDERSTANMD THE QUESTION)

124. A mentally retarded patient became pregnant. The patient does not want an abortion. Her

mother and husband want an abortion. What should a physician do in this situation? (Important)
Answer: abortion should not be performed.BCUZ SHE IS COMPETENT UNLESS PROVED OTHERWISE

125. A male physician is examining an adolescent or adult female patient. What should a physician

do in this situation? (Important)
Answer: a chaperone should be present during the physical examination. The same rules apply when

a physician is examining a patient who appears to be seductive. (Important)

126. A female physician is examining an adolescent or adult male patient. What should a physician

do in this situation? (Important)
Answer: a chaperone should not be present during the physical exam.

127. A suspected HIV patient expired in a car accident. He signed for organ donations. What
should a physician do in this situation?
Answer: his HIV status is not certain. The organs can be preserved until the HIV status is

confirmed. If the test for HIV is positive, organs should be discarded.

128. A patient who expired in a car accident signed in his license foe organ donations. His

license has expired. He always wanted to donate his organs. What should a physician do in this

situation? (Important)
Answer: physican cannot accept organs because the signed consent has expired.ASK FAMILY MEMBERS

ABOUT WISHES OF THE PT IF HE WANTED TO DONATE ORGANS.JUST AHVING AN ORGAN DONOR CARD DOESNT TELL

PT INTENT.MAY BE HE SHUD HAVE DONE TO SHOW OFF OR GET A BONUS OR FORCRD BY SOMEONE.EVEN IF DONOR

CARD HAD NOT EXPIRED AND FAMILY UNANAMOUSLY SAID THAT PT DIDNT WANTED TO DONATE ORGANS DONOT

ACCEPT ORGANS FOR TRANSPLANT

129. A male physician sexually harassed a female patient during the physical examination. The

patient complained to a nurse. What should the nurse do in this situation?
Answer: the nurse should tell the patient to make an official report to the hospital authority or

to an appropriate agency.

130. A chronic male smoker comes to the physician for his heart problems. The physician wanted

his patient to quit smoking. What should the physician advise in this situation?
Answer: the physician should ask the patient to quit smoking immediately because patients are

usually more responsive when they are ill. The physician should assist the smoker to move one

step closer to quitting.

131. A terminally ill patient did not sign a DNR (do not resuscitate) order, however, he signed a

DNI (do not intubate) order. What should the physician do in this situation?
Answer: the physician should follow his orders i.e., the patient should be resuscitated but

should not be intubated, despite severe hypoxic condition of the patient.

132. A terminally ill patient signed a DNR order, however, he did not sign a DNI (do not

intubate) order. He wants to be intubated but not resuscitated. What should a physician do in

this situation?
Answer: the physician should follow his orders i.e., the patient should be intubated but should

not be resuscitated.

133. An adolescent car accident victim was brought to the ER in an unconscious state. The patient

needs immediate surgical interventions. The surgeon was unable to contact any family member to

obtain consent. What should a surgeon do in this situation? (Important)
Answer: the surgeon should do the procedure without waiting to obtain a consent for the benefit

of the patient.

134. An obgyn doctor is recently diagnosed with HIV infection. He is receiving medication for

HIV. His physical and mental conditions are normal. Should he tell his patients or fellow

physicians about his HIV status?
Answer: no, however, the doctor should take appropriate precautions for infection control. He

does not have to tell his fellow physicians about his HIV status including the physicians who are

referring patients to him. The doctor is allowed to see patients if he takes appropriate

precautions. However, he should notify the hospital authority.

135. A physician is scared of seeing an HIV patient with an open wound. Can a physician refuse to

see a patient?
Answer: yes, however, a physician’s refusal to see a patient is unethical but is legal.

136. An elderly semicomatose patient may require surgical intervention. His family members are

confused about the surgery. They asked the surgeon for his opinion. What should the surgeon’s

response be?
Answer: the surgeon can give his opinion and act as a moral surrogate for the benefit of the

patient. (Very Important)

137. A 12-year old boy is diagnosed with a terminal illness (e.g., malignancy). He asked the

doctor about his prognosis. His parents requested the doctor not to tell him the bad news. What

should the doctor do in this situation? (Very Important)
Answer: the doctor should tell the truth politely and compassionately to the patient.YES TOTALYY

CORRECT CHILD NEEDS TO BE BE TOLD OF HIS TERMINAL ILLNESS IF HE CAN UNDERSTAND THE SITUATION AND

IRREVERSIBILTY OF DEATH.TRY TO CONVINCE PARENTS FIRST.

138. A 55-year old woman is recently diagnosed with right breast cancer. The doctor told the

patient that she will require surgery for removal of the right breast. She started to cry. What

should a doctor do in this situation?
Answer: first, the doctor should give her some tissue paper for wiping her tears. Then, the

doctor should be sympathetic to her and console her. He might tell her that similar reactions are

usually expected from other patients with breast cancer. Please do not mention that she will be

fine with a breast implant or without a right breast because she is already 55-years old.

139. A mother is carrying a 500 gram premature fetus which develops acute fetal distress. The

physician wanted to perform a cesarean section. Mother refused cesarean section. What should the

doctor do in this situation?
Answer: the physician should arrange a bedside conference with the mother along with other

physicians, social worker, and administrator to discuss the ma

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