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NBME 21 Answers

nbme21/Block 3/Question#39 (24.6 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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submitted by drdoom(682),
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Smte atayclul ,atsest “On nniuosige,qt the ntitpea odse not knwo hte tdae i[]tem, teh mena of eth lsipohta ca]le[p, or eth nema of hre uersn woh adh ujts orudcidtne lmisehf s]eonr[p”. So, tp is dsroitidene to emit and eclpa Cc(oeih ;)A ttha is nftlieiedy nnorncecig -- as ulwod be sspeededr oodm iC(hoce E) nad eht horte oihcesc -- tbu lin“yiabit to nernsadudt yvieetsr and sionos”gpr is het mtso nrgncneico cisne hatt is eht yevr fdiineonti of yicpc.aat iltiabyIn ot ddrnntsuae = aclk of taciapc.y

lovebug  you explain very clearly. THX!!! +  
drdoom  thanks lovebug! +  

submitted by vlodkadrinker(6),
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I yloiousbv htugoht hatt eht nami hgitn orf tacpiayc is to edrdasnutn the risyevet nad rsgsoopni fo reh mcdeali tciondino TUB I ohgthut hsit wsa a rictk unsqeiot ucabees yteh deksa fi" teh amenlt ixoananmtei fiigndn .d.ehs".wo dan het mtes lefdai to mtenion ginyhant atobu ehr iatnoiotren to cpael ro udbm

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  

submitted by fatboyslim(26),

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).

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