Legal Ethics

If a patient is legally dead (brain dead), the physician is authorized to remove life support without a
court order or consent from family
If a competent patient requests cessation of artificial life support, it is both legal and ethical for a
physician to comply with this request
If the physician believes that the patient's health will be adversely affected by the news of a
malignancy, he or she can delay telling the patient the diagnosis until he or she is ready to
receive the biopsy report
A patient (e.g., the father) who is legally competent can refuse lifesaving treatment for himself for
religious or other reasons, even if death will be the outcome. However, a parent (or guardian)
cannot refuse lifesaving treatment for his child for any reason
A pregnant woman has the right to refuse medical tests or treatment even if the fetus will
die or be seriously injured as a result. After the child is born, the mother cannot refuse to have it
tested or treated for HIV
Competent pregnant women, like all competent adults, can refuse medical treatment, even if the fetus
will die as a result
The priority order in which family members make this determination is the 1) spouse, 2) adult children,
3) parents, 4) siblings, and 5) other relatives
With respect to the paternity finding the physician should neither write it in the chart nor
tell the couple. It is not appropriate for physicians to divulge information obtained serendipitously in
the course of genetic testing and unrelated to the purpose of the testing
This girl's parents should be advised not to test the girl for the fragile X gene until she is an adult (at
least 18 years old) and requests the test. Genetic testing for carrier status should be deferred
until either the child reaches maturity, or the child needs to make reproductive decisions."
The first-year resident should ask the attending surgeon to get consent from the patient himself.
Consent cannot be obtained until the patient has been informed and understands the health
implications of her diagnoses, health risks and benefits of treatment, the alternatives to treatment,
likely outcome if she does not consent to the treatment and that she can withdraw consent for
treatment at any time.
Parents can refuse experimental treatment of their child for any reason.
If patient cannot communicate and there is no written instructions next of kin becomes responsible for
medical decisions
DNR: no intubation or mechanical ventilation, no chest compression, no defibrillation
You can give emergency blood transfusion to preserve life of incompetent Jehovas witness when there
is no blood refusal card, no other appropriate treatment options available and communication
with the patients surrogate is inadequate
In nonemergent cases call an interpreter when there is language barrier involving a patient
Patients have the right to refuse to receive medical information. Physicians must also understand and
respect beliefs of cultures that value beneficence over autonomy. In these cultures family members
may be expected to make medical decisions to avoid perceived harm, disrespect or mental
distress caused by direct disclosure to the patient
In an emergency situation physician can share patients medical information when it is in the patients
best interest based on their professional judgement

Dont prescribe antibiotics if it is not bacterial even if patient demands it because of

widespread antibiotic resistance and adverse reactions to antibiotic therapy
Physician can keep pregnancy confidential but should encourage teenager to seek help from her
parents
Pregnancy through Preschool
Children under the age of 6 years do not understand the finality of death and fully expect
dead people to come back to life. It is not until about age 9 that children begin to understand
that they can also die
Loud protests occur initially when the mother leaves the child. With her continued absence this child
experiences other serious reactions including depression, decreased responsiveness to adults, and
deficits in the development of social and motor skills
A 3 year-old children such as this one should have a vocabulary of about 900 words and speak in
complete sentences
Postpartum depression occurs in 5%10% of new mothers and is treated primarily with
antidepressant medication
"Did you experience any emotional difficulties after the birth of your other children?" is an important
question since a predictor of postpartum reactions is whether or not they have occurred before.
This patient is probably worried because she has had previous problems
It is normal for a 3-year-old child to have difficulty sitting still for any length of time. By school age,
children should be able to sit still and pay attention for longer periods of time
Transferring objects from hand to hand commonly occurs at about 10 months of age.
Infants can usually turn over at about 5 months of age.
Children begin to show social smiling between 1 and 2 months of age.
Children begin to respond to their own names between 7 and 11 months of age.
Children begin to use a utensil to feed themselves at about 2 years of age
School Age, Adolescence and adulthood
Parents should be present when a physician speaks to a younger child but teenagers usually should be
interviewed, particularly about sexual issues, without parents present
The best time to tell a child she is adopted is as soon as possible, usually when the child can first
understand language
Teenagers who become pregnant frequently are depressed, come from homes where the parents are
divorced, have problems in school, and may not know about effective contraceptive methods.
While midlife is associated with the possession of power and authority, physical abilities decline. This
time of life is also associated with a midlife crisis, which may include increased alcohol and drug use as
well as an increased likelihood of change s in social and work relationships.
Tanner stages:
1. Genitalia and associated structures are the same as in childhood; nipples (papillae) are slightly
elevated in girls. Pubic hair consists of fine villus hair. Turner syndrome
2. Scant, straight pubic hair, testes enlarge, scrotum develops texture; slight elevation of
breast tissue in girls
3. Pubic hair increases over the pubis and becomes curly, penis increases in length and testes
enlarge
4. Penis increases in width, glans develops, scrotal skin darkens; areola rises above the rest
of the breast in girls

5. Male and female genitalia are like adult; pubic hair now is also on thighs, areola is no longer
elevated above the breast in girls
The formation of a personal identity is usually achieved during the teenage years
The concepts of seriation and conservation and an understanding of the concept of "fair play" are
gained during the school-age years
Leading killer of African American men between ages of 25-34 is unintended injury (accidents).
Between 15-24 - homicide

Genetics, Anatomy and Biochemistry of Behavior

Placebo response is based in part on activation of the endogenous opioid system
Anxiety, abdominal cramps and diarrhea, and skin flushing are symptoms of pheochromocytoma NE
secreting adrenal tumor
The corpus callosum and the hippocampal, habenular, and anterior commissures connect the two
hemispheres of the brain.
Histamine receptor blockade with drugs such as antipsychotics and tricyclic antidepressants is
associated with common side effects of these drugs such as sedation and increased appetite
leading to weight gain
Glutamate contributes to the pathophysiology of disorders such as schizophrenia, Alzheimer
disease, and other neurodegenerative illnesses.
Memantine a blocker of the N-methyl-d-aspartate (NMDA) receptor, a type of glutamate receptor, has
been approved to treat Alzheimer disease and may prove useful also in the treatment of schizophrenia
NE is metabolized to MHPG
Klver-Bucy syndrome, which includes hypersexuality and docility and is associated with damage to
the amygdala
Sleep-arousal mechanisms are affected by damage to the reticular system
Brains of patients with schizophrenia are likely to show decreased volume of limbic structures
such as the hippocampus; increased size of cerebral ventricles due, in part, to brain shrinkage;
and decreased glucose utilization in the frontal cortex
Depression is most likely to be associated with damage to the left frontal lobe
Assaultive, impulsive, aggressive behavior is associated with decreased levels of serotonin in the
brain. Levels of 5-HIAA (5-hydroxyindoleacetic acid), the major metabolite of serotonin, have been
shown to be decreased in the body fluids of violent, aggressive, impulsive individuals as well as
depressed individuals. MHPG (3-methoxy-4- hydroxyphenylglycol), a metabolite of
norepinephrine, is decreased in severe depression
Behavioral changes such as decreased impulse control, poor social behavior, and lack of characteristic
modesty indicate that the area of the brain most likely to have been injured in this patient is the
orbitofrontal cortex. Lesions of this brain area result in disinhibition, inappropriate behavior, and poor
judgment. In contrast, lesions of the dorsolateral convexity of the frontal lobe result in decreased
executive functioning (e.g., motivation, concentration, and attention)
Nucleus ceruleus NE, dorsal pons
Raphe nuclei of brainstem serotonin
Nucleus basalis of Meynert cell bodies of cholinergic neurons
Biological Assessment of Patients with Psychiatric Symptoms

The Bender Visual Motor Gestalt Test is used to evaluate visual and motor ability by reproduction of
designs. The Luria-Nebraska neuropsychological battery is used to determine cerebral dominance and
to identify specific types of brain dysfunction, while the Halstead-Reitan battery is used to detect and
localize brain lesions and determine their effects
Intravenous administration of sodium lactate can help identify individuals with panic disorder since
it can provoke a panic attack in such patients
Positron emission tomography (PET) localizes physiologically active brain areas by measuring glucose
metabolism. Thus, this test can be used to determine which brain area is being used during a specific
task (e.g., translating a passage written in Spanish)
Evoked EEGs measure electrical activity in the cortex in response to sensory stimulation
The amobarbital sodium (Amytal) interview is used to determine whether psychological factors are
responsible for symptoms in this patient who shows a non-medically explained loss of sensory function
(conversion disorder)
Computed tomography (CT) identifies organically based brain changes, such as enlarged ventricles.
Thus, although not diagnostic, this test can be used to identify anatomical changes in the brain, such
as enlarged ventricles in a patient with suspected dementia of the Alzheimer type
Poor appetite, poor sleep, and lack of interest in normal activities characterize patients who have
major depression. In this depressed woman, the dexamethasone suppression test is likely to be
positive. A positive result is seen when the synthetic glucocorticoid dexamethasone fails to
suppress the secretion of cortisol as it would in a normal patient. Also, in depression there
may be abnormal growth hormone regulation and melatonin levels, and decreased 5-HIAA
Hyperthyroidism is more commonly associated with the symptoms of anxiety.
Scores below 20 on the Folstein Mini-Mental State Examination indicate significant cognitive
impairment. This test does not evaluate calculating ability or IQ. Although the patient is impaired, it is
not clear what caused the problem or whether she needs to be placed in an assisted living facility
Psychoanalytic Theory and Defense Mechanisms
In Freud's structural theory, the mind is divided into the id, ego, and superego. The id operates
completely on an unconscious level, while the ego and superego operate partly on an unconscious and
partly on preconscious and conscious levels. Id is present at birth instinctive sexual and aggressive
drives not influenced by external reality. Ego develops after birth controls expression of Id by the use
of defense mechanisms and reality testing. Superego begins to develop at 6 years and is associated
with morals and conscience.
Sublimation, expressing an unacceptable emotion in a socially acceptable way, is classified as a
mature defense mechanism. Denial, dissociation, regression, and intellectualization are all classified as
less mature defense mechanisms
Primary process thinking is associated with pleasure seeking, disregards logic and reality, has no
concept of time, and is not accessible to the conscious mind. Secondary process thinking is logical and
is associated with reality.
Memory of the details of the Krebs cycle, while no longer in the forefront of the medical student's mind,
can be recalled relatively easily 1 week after the examination. This memory therefore resides in the
preconscious mind. The unconscious mind contains repressed thoughts and feelings, which are not
available to the conscious mind. The conscious mind contains thoughts that a person is currently
aware of
Fantasy immature defense mechanism that substitutes an imaginary less disturbing view of the world
to avoid awareness of painful feelings

Learning Theory
Habituation continued exposure to a stimulus (the fire alarm, in this example) results in a
decreased response to the stimulus. Thus, while the students respond quickly to the fire alarm at
first, with repeated soundings of the alarm, they ultimately fail to respond to it. If sensitization had
occurred, the students would have responded more quickly with each exposure to the
alarm
The cerebellum participates in classical conditioning, specifically in associations involving motor
skills.
The unconditioned response is reflexive and automatic and does not have to be learned. The
unconditioned stimulus (pizza) is the only element here that by itself will elicit a natural GI reflex
(stomach growling)
By classical conditioning, the animal learns that there is an association between an aversive stimulus
(e.g., painful electric shock) and the inability to escape. Subsequently, the animal makes no attempt to
escape when shocked or when faced with any new aversive stimulus; instead, the animal becomes
hopeless and apathetic. Learned helplessness in animals may be a model system for depression
(often characterized by hopelessness and apathy) in humans.
In stimulus generalization, a new stimulus (e.g., a church bell) that resembles a conditioned
stimulus (e.g., the lunch bell) causes a conditioned response (e.g., salivation)
Shaping involves rewarding closer and closer approximations of the wanted behavior until the correct
behavior is achieved (e.g., a child learning to write is praised when she makes a letter, even though it
is not formed perfectly)
Tips for behavioral modification
Asking patients to make big changes is often not successful
A better approach is to break down changes into increments and use a step by step approach
(shaping) to gradually change behavior
Modeling is a type of observational learning (e.g., an individual behaves in a manner similar to that of
someone she admires)
Assessment of Patients with Behavioral Problems
Normal intellectual function (IQ 90109)
IQ = MA/CA 100
Mild (IQ 5070)
Moderate (IQ 3555)
Severe (IQ 2040)
Profound (IQ < 20)
A score between 71 and 84 indicates borderline intellectual functioning.
Minnesota Multiphasic Personality Inventory-2 (MMPI-2) evaluate depression as well as
hypochondriasis, paranoia, schizophrenia
Vineland Social Maturity Scale is used to evaluate skills for daily living
For evaluating depression in this patient using a self-rating scale, the most appropriate test is the Beck
Depression Inventory-II
Wisconsin Card Sorting Test is the most appropriate test for evaluating abstract reasoning and problem
solving in a patient
Substance Abuse

Amphetamines like "speed" reduce appetite; use can thus result in decreased body weight.
Amphetamines also decrease fatigue, increase pain threshold, and increase libido
Heroin users show an elevated, relaxed mood and somnolence
Withdrawal from benzodiazepines is associated with tremor, insomnia, and anxiety. Withdrawal from
barbiturates can cause the same and also seizures
Major mechanism of action of cocaine is to block reuptake of dopamine
The presence of HIV as well as signs of sedation and euphoria indicate that this patient is an
intravenous heroin user
Violence and subsequent trauma are most common causes of death in PCP use
Normal Sleep and Sleep Disorders
Sedative agents have a high abuse potential and because they tend to reduce REM and delta sleep,
their use may result in sleep of poorer quality
Theta waves are primarily seen in stage 1 sleep.
In young adults, 45% of total sleep time is spent in stage 2 sleep. Five percent is spent in stage 1, 25%
in REM, and 25% in delta sleep.
Sleep in major depression is associated with increased REM sleep, reduced delta sleep, and decreased
sleep latency
Sleep in elderly patients is characterized by increased stage 1 and stage 2 sleep, increased nighttime
awakenings, decreased REM sleep, and much reduced or absent delta sleep
Kleine-Levin syndrome is usually seen in adolescents and involves recurrent periods of hypersomnia
and hyperphagia, each lasting 13 weeks
At the end of the month, the length of this student's circadian cycle in the absence of cues from the
outside world is likely to be close to 25 hours. Student slept in cave for one month with no access to
clocks or watches
Narcolepsy with cataplexy is most often caused by the lack of neuropeptides hypocretin-1 (orexin A)
and hypocretin -2 (orexin B) produced by neurons in the lateral hypothalamus. They promote
wakefulness
Schizophrenia and Psychotic Disorders
In patients with schizophrenia, the size of cerebral ventricles, glucose utilization in the frontal lobes,
and size of limbic structures are most likely to be increased, decreased, and decreased,
respectively
Schizoaffective disorder is characterized by symptoms of a mood disorder, as well as psychotic
symptoms, and lifelong social and occupational impairment
Disorganized schizophrenia is characterized by disinhibition, poor grooming, poor personal
appearance, and inappropriate emotional responses
Positive symptoms such as delusions respond better to antipsychotic medication
Negative symptoms respond better to atypical antipsychotic medication than to traditional
antipsychotics
An illusion is a misperception of a real external stimulus (e.g., a computer looking like a lion
lurking in the corner in a darkened room). A hallucination is a false sensory perception

Neuropsychological evaluation of a patient with schizophrenia is most likely to reveal frontal lobe
dysfunction. People with schizophrenia usually show intact memory; orientation to person, place, and
time; and normal intelligence
The chance that the son (or other first-degree relatives) of a person with schizophrenia will develop the
disorder over the course of his life is approximately 10%. The chance that the identical twin of a
person with schizophrenia will develop the disorder over the course of his or her life is approximately
50%
Mood symptoms are associated with a good prognosis in schizophrenia. A good prognosis is also
associated with older age of onset, positive symptoms, and few relapses
Delusional disorder - fixed, non-bizarre delusional system (paranoid in the persecutory type); few, if
any, other thought disorders; and relatively normal social and occupational functioning
Psychosis due to a general medical condition psychotic symptoms as a result of a physical illness.
The abnormal gait, age of the patient, and family history strongly suggest Huntington disease, which
can present with psychiatric symptoms such as psychosis and depression
Mood Disorders
A 55 year old man suffered from stroke, lives alone risk for major depressive disorder
When compared with a man, a woman is twice as likely to develop major depressive disorder, and
three times as likely to develop dysthymic disorder. Bipolar disorder and cyclothymic disorder occur
equally in men and women
Preoccupation with feelings of guilt are more characteristic of depression than sadness about being
very ill
In atypical depression, patients overeat and oversleep
Chances of the monozygotic twin and first-degree relative (e.g., brother) of this bipolar patient
developing the disorder are about 75% and 20%, respectively
One most effective for cyclothymic disorder, as for bipolar disorder, is lithium
In bipolar disorder, there are episodes of both mania and depression (bipolar I disorder) or both
hypomania and depression (bipolar II disorder)
To diagnose schizoaffective disorder psychosis must occur in the absence of major mood
episodes but mood symptoms have to be present for most of the illness.
In major depressive or bipolar disorder wit psychotic features psychotic symptoms occur
exclusively during mood episodes
Schizophrenia Mood symptoms are absent or present for only brief periods
Schizoaffective disorder: Multiple psychotic episodes with concurrent major depressive or manic
symptoms
Anxiety, Somatoform, Factitious Disorder and Malingering
Panic disorder - increased heart rate, dizziness, sweating, shortness of breath, and fainting, and the
conviction that one is about to die. Attacks commonly occur twice weekly, last about 30 minutes, and
are most common in young women. Most effective immediate treatment for this patient is a
benzodiazepine because it works quickly, the most effective long-term (maintenance) treatment is
an antidepressant, particularly a selective serotonin reuptake inhibitor (SSRI) such as paroxetine
(Paxil)
The most effective long-term treatment for PTSD is a support group. Pharmacologic treatment can be
used as an adjunct to psychological treatment

GAD - tingling in the extremities, often resulting from hyperventilation.

Conversion disorder sudden hemiparesis patient does not care abt it (la belle indifference)
Cognitive, Personality and Eating Disorders
Anorexia is also characterized by family conflicts, particularly with the mother, normal appetite,
high interest in food and cooking, low sexual interest, good school performance, and
excessive exercising
Pseudodementiadepression that mimics dementia
Borderline personality disorder - typically use splitting (see Chapter 6) as a defense mechanism. Selfinjurious behavior and impulsive behavior (e.g., drug abuse, sex with multiple partners) also
are characteristic of people with this personality disorder
Dissociative identity disorder (formerly multiple personality disorder). She does not remember the man
who signed the letter or posing for the photograph because these events occurred when she was
showing another personality.
Dissociative amnesia involves a failure to remember important information about oneself, and
dissociative fugue is amnesia combined with sudden wandering from home and taking on a different
identity
Histrionic personality disorder act rashly without thinking
Psychiatric Disorders in Children
Rett disorder - Diminished social, verbal, and cognitive development after up to 4 years of
normal functioning. Occurrence only in girls (Rett disorder is X-linked and affected males die before
birth). Stereotyped, hand-wringing movements; ataxia, Breathing problems, Mental retardation,
Motor problems later in the illness
Children with oppositional defiant disorder have problems dealing with authority figures but not with
other children or animals as in conduct disorder also stealing
Obsessive-compulsive disorder (OCD) is particularly associated with Tourette disorder
Psychopharmacology
Tardive dyskinesia usually occurs after at least 6 months of starting a high-potency antipsychotic and
is best treated by changing to a low-potency or atypical agent; stopping the antipsychotic
medication will exacerbate the symptoms
Neuroleptic malignant syndrome is seen most commonly with high-potency antipsychotic treatment
and is best relieved by stopping the antipsychotic medication, providing medical support, and
administering dantrolene, a muscle relaxant. After recovering from this life-threatening condition,
the patient can be put on an atypical agent which is less likely to cause this dangerous side effect
ECT is a safe, fast, effective treatment for major depression if other antidepressant medications are not
working
Atypical agents, like clozapine are more effective against negative symptoms (e.g., withdrawal) than
typical antipsychotics
Amoxapine drug used for major depression. Has antidopaminergic action and, thus, is the agent
most likely to cause gynecomastia as well as parkinsonian symptoms in a patient.

SSNRIs may work more quickly than other antidepressants and, as such, venlafaxine is a
good choice for rapid relief of depressive symptoms
Imipramine, a tricyclic antidepressant, is most likely to cause flattening of T waves and prolonged QT
interval. Nortriptyline is the least likely of the cyclic agents to cause these changes
Dopamine normally suppresses acetylcholine activity, giving the patient an anticholinergic agent (e.g.,
benztropine) will serve to increase dopaminergic activity and relieve the patient's symptoms drug
induced Parkinson symptoms
Opioid analgesics now number 1 cause of overdose deaths in US
Psychological Therapies
Systematic desensitization is based on classical conditioning. The film of people entering elevators
in a high-rise building is paired with relaxation
Biofeedback is based primarily on operant conditioning
Reciprocal inhibition is the mechanism that prevents one from feeling two opposing emotions at the
same time (e.g relaxation and fear), and is associated with systematic desensitization
In aversive conditioning, classical conditioning is used to pair a maladaptive but pleasurable stimulus
with an aversive or painful stimulus
Implosion - person is instructed to imagine extensive exposure to a feared stimulus
Sexuality
Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) are more likely to cause delayed or
absent orgasm
Propranolol (beta blockers), clonidine, methyldopa can cause erectile dysfunction
Aging is also characterized by a longer refractory period and delayed ejaculation in men and
decreased intensity of orgasm in men and women
Patient's erectile problems are most likely to be associated with his alcohol drinking. Cigarette
smoking is less likely than alcohol to affect sexual function
Most common cause of pelvic inflammatory disease (PID) in women is chlamydial infection
Physician Patient Relationship
Obsessive-compulsive patients fear loss of control and may in turn become controlling
(e.g., having the physician wait while he makes a phone call) during illness
There is no clear association between compliance and race, socioeconomic status, education, or
gender
Psychosomatic Medicine
Chronic pain patient is at high risk for depression
Because of the disorienting nature of the ICU, delirium is commonly seen in ICU patients.
Health Care in the US
Medicare
Part A: Inpatient hospital care, home health care, medically necessary nursing-home care for a
limited time after hospitalization, hospice care

Part B: Physician fees, dialysis, physical therapy, laboratory tests, ambulance service, medical
equipment (Part B is optional and has a 20% co-payment and a $100 deductible)
Part D: Prescription drug coverage
Medicare does not cover long-term nursing home care

Medicaid
Inpatient and outpatient hospital care, Physician services, Home health care, e.g hospice care,
laboratory tests, dialysis, ambulance service, medical equipment, Prescription drugs, Longterm nursing home care, Dental care, eyeglasses, hearing aids
No co-payment or deductible
Patients have the most choice in choosing a physician in a traditional fee-for service indemnity
plan. In this type of plan there are no restrictions on provider choice or referrals. Managed care plans
(e.g., health maintenance organizations [HMOs], preferred provider organizations [PPOs], and point of
service [POS] plans) have restrictions on physician choice. Patients have the least choice in choosing a
physician in an HMO. HMOs are the most restrictive of managed care plans for the patient in terms of
choice of physician. Rather than choosing a physician from the network as in a PPO or POS, in an HMO
the patient is assigned a physician
Most common cause of death in infants up to 1 year of age is congenital anomalies
Dont ask questions when you are trying to educate patient about plan of treatment, intervention or
disease
Biostats:
Want to see if it is children being exposed to chemical waste products leading to AML case
control study.
Control group: children both with and without exposure to the chemical waste who do not
suffer from AML