Case: 10-1: Is There a Duty to Warn?

Question 1: Discuss the ethics- related principles, precedents, and concepts relevant to this case.
Nothing is more challenging or more important than our work with the patient with mental health issues. This case looks at the patients that are threatening physical violence and our duty as nurses to the patient and to the public.

**Read Case Study Below and Answer Question 2 Below***

Angela’s Story: A Case Study on the Reproductive System

You are a columnist for a popular website that deals with women’s health issues. Visitors to the site can submit their stories and questions through an “Ask the Expert” link on the site. In this scenario, a 26-year-old woman has posted her story and some questions regarding reproductive health. My name is Angela. I am a 26-year-old married woman with no children. My husband, Doug, and I have been trying to get pregnant for over two years now and my doctor has suggested that I consider fertility drug treatments. The irony of our situation is that I have been taking a birth control pill for five years to prevent getting pregnant, and now my doctor suggests that I take another drug to help me get pregnant.

When I went off birth control, about a year ago, my menstrual cycle became very irregular. I had been taking a birth control drug called Ortho Tri-Cyclen. To be perfectly honest, I don’t understand how it works because my periods were more regular when I was on the pill than when I went off of it. My doctor told me that the pill works because it tricks your body into thinking that it is pregnant. That just confused me even more.

When I looked back on my decision to take birth control pills, I realized that I did not really understand how they work. I just do not want to make that mistake again. Before I consider taking any more drugs, I want to understand more about how they work. The drug we’re looking into is called Clomid. I asked my doctor a bunch of questions, but I still feel confused. I looked up some stuff online when I got home. Here is some information that I learned from a website about how Ortho Tri-Cyclen works:

Estrogen and progestin work in combination to suppress the hypothalamic-pituitary-gonadal (HPG) axis. This suppression leads to a decrease in the release of gonadotropin-releasing hormone (GnRH) from the hypothalamus and luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the anterior pituitary. Maturation of the dominant follicle is inhibited under the decreasing levels of FSH and LH. Hormonal contraceptive use also leads to an increase in the viscosity of the cervical mucus, which inhibits sperm penetration and movement through the cervical canal.
I am hoping that you would be able to help me understand how these drugs actually work.

Question 2. My doctor also explained that birth control pills “trick the body into thinking it is pregnant.” She explained that women do not normally ovulate when they are pregnant. Can you explain to me why a pregnant woman does not ovulate? How is this related to how the birth control pill works?

**Read Case Study Below and Answer Question 3 Below***

Question 3: Pick your own topic. Briefly give an example of something you find interest within anatomy/physiology course & relate it to a real-life example. It can be something you saw on TV or in a movie, read in a book or magazine, or it can be a personal experience (Please – do not make it too graphic). It can be from any topic we have covered so far in the course (including muscle). Here are 2 examples to help you:

Example #1: I was watching an episode of the TV show “Bones”. The episode was called “The woman & child in the bay” and was a play on the Laci Peterson case. In the opening scene, the body is found. As Bones is examining the body, she says that the pelvis structures indicate the victim was female (they also find her baby). In addition, Bones holds up the arms & says, “She has defensive wounds, her sphenoid is broken.” After studying the skeletal system, I know this is wrong. The sphenoid bone is a bone found in the skull, not the arm & wrist. I think Bones really meant the scaphoid bone, as that is a carpal found in the wrist.

Example #2: My dog’s bloodwork indicated that his calcium was high and his urine showed low specific gravity (too much water). These could be early warning signs of kidney failure or bone cancer. In bone cancer, osteoclasts break down the bone faster than it is rebuilt thus releasing calcium into the blood stream. This is also true of old age (osteoporeosis). My dog is 9 years old, so this could be just normal wear & tear associated with aging. I know from the skeletal chapter and endocrine chapter that the kidneys are stimulated by PTH to reabsorb calcium from the urine. If the kidneys are failing, this would not occur and calcium levels would remain high. These high levels may also indicate a problem with the endocrine glands that secrete the hormones that regulate calcium absorption.

***Read and Answer Question 4 below**

Question 4: We tend to regularly consume certain food products. Most processed food products contain food additives to enhance flavors, maintain color and texture, and preserve freshness. Select a processed food product that you regularly eat and create a list of its ingredients. (If you only consume foods prepared from basic ingredients, select a commonly used food product.) List the food additives in this product and describe the function of each. After learning about the food additives contained in this product, will you continue to purchase this product? Why or why not?

In clinical settings, patients often present with many different types of anemia. Each type of anemia has its own causes and implications. For this reason, you must be able to differentiate between types of anemia as well as identify factors that put patients at greater risk of experiencing related complications. As you prepare for this Discussion, consider the following patient case studies:
Case Study 1
An 82-year-old female presents to the office complaining of fatigue, dizziness, weakness, and increasing dyspnea on exertion. She has a past medical history of atrial fibrillation, hypertension, and hyperlipidemia. Medications include warfarin 2 milligrams po daily, lisinopril 10 milligrams po daily, and simvastatin 10 milligrams po daily. There are no known drug allergies. The physical exam reveals a 5’2” older female. Her weight is 128 pounds, blood pressure is 144/80, heart rate is 98, temperature is 98 degrees Fahrenheit, and O2 saturation is 98%. Further examination reveals the following:
Eyes: + pallor conjunctiva
Cardiac: irregular rhythm. No S3 S4 or M. NO JVD
Lungs: CTA w/o rales, wheezes, or rhonchi
Abdomen: soft, BS +, + epigastric tenderness. No organomegaly, rebound, or guarding
Rectal: no stool in rectal vault

To prepare:
• Review Chapter 237 in Part 21 of the Buttaro et al. text.
• Select one of the three case studies. Reflect on the provided patient information including history, physical exams, and lab reports.
• Think about a differential diagnosis. Consider the role the patient history, physical exam, and lab reports played in the diagnosis.
• Reflect on the pathophysiology of the type of anemia that you diagnosed, as well as potential treatment options. Consider the causes of this type of anemia. Think about whether the patient should be referred for specialized care.
By Day 4
Post an explanation of the differential diagnosis for the patient in the case study that you selected. Describe the role the patient history, physical exam, and lab reports played in the diagnosis. Finally, explain the pathophysiology of the type of anemia that you diagnosed, as well as potential treatment options. Include causes for this type of anemia.
Read a selection of your colleagues’ responses.