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During written interrogatories purchase carafate 1000 mg fast delivery chronic superficial gastritis definition, the plain- tiff attorney will pose a limited number of detailed written questions for you (in conjunction with your attorney) to reply to under oath (1 purchase carafate 1000 mg otc prepyloric gastritis definition,2). Another aspect to discovery is oral interrogation, also known as a deposition. Well before the deposition, the defendant should insist on a meeting with his or her lawyer. Also, if something new or unexpected arises, there will be time to deal with it. It is reasonable to have someone from your From: Medical Malpractice: A Physician’s Sourcebook Edited by: R. It is important to note that everything you write is discoverable except for direct communications to your lawyer. Consequently, if you are going to keep written notes, it is advised that you record only facts and not opinions. DISCOVERY: DEPOSITION The purpose of a deposition is discovery by both sides so that there are no surprises at trial. The deposition is the most important event for the defendant physician before trial (1–7). However, one can ask to have it in a setting in which the pathologist feels more com- fortable, such as in the hospital. The deposition is typically attended by a court reporter, who will record everything. There may be other defense attorneys present if they represent other parties within the lawsuit, such as code- fendant physicians or the hospital. The possibility exists that the plaintiff’s family could also be present. The deposition is taken under oath and can be read to the jury at trial. The format of the deposition is for the opposing (plaintiff’s) attorney to pose a series of questions (cross- examination). Your defense attorney will follow, typically with fewer questions, to clarify certain points raised during cross-examination. Bring your curriculum vitae, but do not bring literature or notes because they will be discoverable. Plaintiff’s Goal: To Be Educated About Your Strategies and Information The defendant’s or physician’s role is not to educate the opposing attorneys, but rather just to answer their questions: • Do not volunteer unnecessary information. If you provide them with information they did not request, it may deprive your attorney of determining when certain information will be disclosed for maximal impact. Providing a lengthy discourse may open up fur- ther questions or opinions that may be detrimental to your case. The attorney Chapter 5 / Discovery and Deposition 55 may be waiting for you to offer additional information that could eventually be damaging to your case. Plaintiff’s Goal: To Impeach Your Credibility What you answer at deposition is sworn testimony and can be read back at trial to make you look bad if there are certain internal incon- sistencies or differences in trial testimony. The role of the physician in this regard is to tell the truth and to be consistent. Assume that any misstatement will be discovered, and it will be made to look like nothing that you say can be trusted. This allows you to think carefully before answering, and it allows time for your attorney to raise objections. Do not panic, because these mistakes can be rehabilitated at trial or when your attorney follows up with questions. The following are some specific ploys used by plaintiff lawyers to ruin your credibility. Plaintiff attorney: Asks specifically ambiguous questions so that you will answer them in an incriminating manner. Defending physician: Do not help the plaintiff attorney by saying, “Do you mean X or Y?

The form of the QRS will be normal curs later and is a step involved in the activation of because electrical excitation of the ventricles occurs both the intrinsic and the extrinsic pathways purchase carafate 1000mg otc gastritis heartburn. With complete bin to thrombin and conversion of fibrinogen to fibrin heart block 1000mg carafate fast delivery gastritis diet , P waves and QRS complexes are com- are the final steps that lead to clot formation by either pletely independent of each other. There will not be a consistent ratio of P waves to QRS complexes Chapter 12 because the two are disassociated, but the average ra- tio would be 80/40 or 2:1. Changes be significantly different from normal because depolar- in transmural pressure can be caused by changes inside ization now originates in the right ventricle and prop- or outside of a vessel (see equation 5). Because the right side of blood does not directly affect transmural pressure. Re- the heart depolarizes before the left, the configuration sistance, not transmural pressure, is proportional to the of the QRS may resemble that seen with left bundle length of a tube. When the heart stops, blood contin- of the heart depolarizes before the left. The duration of ues to flow from the arteries to the veins until the pres- the QRS complex will be increased because the spe- sures in the two sides of the circulation are equal. That cialized conducting system of the ventricles is not fully pressure is mean circulatory filling pressure. Hemody- employed: Depolarization moves through more slowly namic pressure is the potential energy that causes conducting muscle instead of the rapidly conducting blood to flow. Retrograde conduction through the pressure in the aorta or a large artery over the cardiac AV node is extremely unlikely, so P waves will not fol- cycle. Because excitation of the atria the pressure inside and outside a blood vessel. Hydro- and ventricles is still independent, there will be no pre- static pressure is the pressure caused by the force of dictable PR interval. Although flow velocity, viscosity, marily responsible for the upswing of the action poten- and tube diameter all influence turbulence, it is the tial (phase 0) of nodal cells. Voltage-gated Na chan- combination of these variables (plus the density of nels are inactivated because the resting membrane blood), expressed as the Reynolds number (equation 4 potential in these cells never becomes sufficiently nega- in the text), that determines whether flow is turbulent tive to allow reactivation. Inward rectifying K channels are responsible for maintaining Compliance V/ P the resting membrane potential in nonnodal cells but 30 mL/40 mm Hg have a less important role in cells with a pacemaker po- 0. A dipole is created by atrial analogous to the systemic circulation in which there repolarization but it is not observed on the ECG be- are many branches. The overall resistance can be cal- cause the dipole created by ventricular depolarization culated from the sum of the flows through the individ- is much larger. In lead I, when the ECG is smallest when the mean axis is directed perpendicu- electrode attached to the right arm is positive relative lar to a line drawn between the two shoulders because to the electrode attached to the left arm, a downward de- both electrodes are equally influenced by the negative flection is recorded. When cardiac cells are depolarized, the inside of occurs during a period when both ventricles are com- the cells is positive or neutral relative to the outside of pletely depolarized. Stimulation of the sympathetic nerves Chapter 14 to the normal heart decreases the duration of the ven- tricular action potential and, therefore, decreases the 1. As heart rate increases, the duration of di- because stroke volume is increased at a constant pre- astole and, therefore, the TP interval decreases. When loop B is compared to loop creased conduction velocity in the AV node decreases A, preload is not increased or decreased because there the duration of the PR interval. Fewer P waves than is no change in the pressure or volume at which the mi- QRS complexes are indicative of AV block. The frequency of QRS complexes increases the pressure or volume at which the aortic valve opens with the heart rate. The drug could act on 1-adrenergic is increased is the larger volume difference between the receptors to increase the rate of depolarization of point at which the aortic valve opens and closes—that sinoatrial nodal cells. An adrenergic receptor antago- is, between isovolumetric contraction and relaxation. The aortic and mitral valves are never ergic receptor agonist and the closing of voltage-gated open at the same time. The first heart sound is caused by clo- K channels would slow pacemaker depolarization by sure of the mitral and tricuspid valves. The mitral valve keeping the membrane potential closer to the K equi- is open throughout diastole except isovolumetric relax- librium potential. Excitation of the ventricles does not sure during diastole and isovolumetric contraction but ordinarily lead to excitation of the atria because retro- is greater than aortic pressure during a substantial pe- grade conduction in the AV node is unusual.

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Select the (A) Salt concentration is increased (A) Propagation of the action potential ONE lettered answer or completion that is beneath the myelin segments (B) The function of voltage-gated ion BEST in each case order 1000 mg carafate mastercard gastritis gel diet. A pharmacological or physiological (C) Membrane resistance is decreased synaptic vesicles to the presynaptic perturbation that increases the resting beneath the segments of myelin membrane PK/PNa ratio for the plasma membrane (D) Voltage-gated sodium channels are (D) The binding of transmitter to the of a neuron would concentrated at the nodes of Ranvier postsynaptic receptor (A) Lead to depolarization of the cell (E) Capacitance is decreased at the (E) The reuptake of neurotransmitter (B) Lead to hyperpolarization of the nodes of Ranvier by the presynaptic cell cell 4 cheap carafate 1000 mg without a prescription gastritis diet . What property of the postsynaptic (C) Produce no change in the value of regions of CNS axons lose their myelin neuron would optimize the the resting membrane potential sheath. The afterhyperpolarization phase of constant of these unmyelinated regions axodendritic synapses? A gardener was accidentally poisoned (D) Peptide transmitters of the antibodies impairs ion channel by a weed killer that inhibits (E) Second messenger transmitters opening and would likely cause acetylcholinesterase. A teenager in the emergency department (A) Decreased nerve conduction following alterations in neurochemical exhibits convulsions. The friend who ac- velocity transmission at brain cholinergic companied her indicated that she does (B) Delayed repolarization of axon synapses is the most likely result of this not have a seizure disorder. A 45-year-old lawyer complains of and human neurological disease: Re- cholinergic receptors nausea, vomiting, and a tingling feeling (E) Increased synthesis of choline cent progress, prospects, and chal- in his extremities. His client catecholamines from the synaptic cleft is Geppert M, Sudhof TC. New (E) Endocytosis by the postsynaptic (C) Ingestion of a toxin that blocks York: McGraw-Hill, 2000. A patient in the emergency department (D) Ingestion of a toxin that blocks nelopathies: Their contribution to our exhibits psychosis. Pharmacological nerve-muscle transmission knowledge about voltage-gated ion intervention to decrease the psychosis channels. News Physiol Sci (E) Cerebral infarct (stroke) would most likely involve 1997;12:105–112. Neurobiology: Molecules, potential is recorded from the neurotransmission Cells and Systems. Malden, MA: Black- affected peripheral nerve of a (B) Stimulation of dopaminergic well Science, 1998. Compared to a recording nisms of calcium-dependent excitotoxi- (C) Blockade of nitrergic from a normal nerve, the recording city. The role of mito- neurotransmission (B) Increased rate of rise chondrial dysfunction and neuronal ni- (E) Blockade of cholinergic (C) Lower conduction velocity tric oxide in animal models of neurode- neurotransmission (D) Shorter duration generative diseases. Mol Cell Biochem (F) Stimulation of cholinergic afterhyperpolarization 1997;174:193–197. Nitric be most affected by a toxin that associated with certain types of lung oxide and carbon monoxide: Parallel disrupted microtubules within neurons? Brain Res (A) Amino acid transmitters components of the cancer plasma Rev 1998;26:167–175. CASE STUDIES FOR PART I • • • CASE STUDY FOR CHAPTER 1 derness to the abdomen, and her bowel sounds are hy- peractive. Laboratory results show she is hypokalemic, Severe, Acute Diarrhea with a plasma potassium level of 1. On the last night of her are slightly lower than normal, and plasma bicarbonate is visit, she consumed a dozen fresh oysters. After oral rehy- hours later, following her return home, she awoke with dration and antibiotic therapy, she rapidly improves and nausea, vomiting, abdominal pain, and profuse watery di- is discharged on the fourth hospital day. She went into shock and was transported to the emergency department, where she was found to be dehy- Questions drated and lethargic. CHAPTER 3 The Action Potential, Synaptic Transmission, and Maintenance of Nerve Function 61 Answers to Case Study Questions for Chapter 1 Reference 1. The microorganism responsible for this disease CASE STUDY FOR CHAPTER 3 is Vibrio cholerae. The ingestion of water or food that has been contaminated with feces or vomitus of an individual Episodic Ataxia transmits the bacterium, causing the disease. The pathophysiology associated with this disease is related to cause of visible muscle twitching. The scribed the twitches as looking like worms crawling un- toxin has two subunits ( and ).

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Medical Records Whenever possible and appropriate 1000 mg carafate otc gastritis diet journal template, a record of online communica- tions pertinent to the ongoing medical care of the patient must be maintained as part of cheap 1000 mg carafate visa gastritis symptoms lump in throat, and integrated into, the patient’s medical record, whether that record is paper or electronic. Licensing Jurisdiction Online interactions between a health care provider and a patient are subject to requirements of state licensure. Communications online with a patient outside of the state in which the provider holds a license may subject the provider to increased risk. Authoritative Information Health care providers are responsible for the information that they pro- vide or make available to their patients online. Information that is pro- vided on a medical practice website should come either directly from the health care provider or from a recognized and credible source. Infor- mation provided to specific patients via secure e-mail from a health care Chapter 7 / E-Medicine in the Physician’s Office 85 provider should come either directly from the health care provider or from a recognized and credible source after review by the provider. Commercial Information Websites and online communications of an advertising, promotional, or marketing nature may subject providers to increased liability, includ- ing implicit guarantees or implied warranty. FEE-BASED ONLINE CONSULTATIONS ERISK GUIDELINES A fee-based online consultation is a clinical consultation provided by a medical provider to a patient using the Internet or other similar elec- tronic communications network in which the provider expects payment for the service. An online consultation that is given in exchange for payment intro- duces additional risks. In a fee-based online consultation, the health- care provider has the same obligations for patient care and follow-up as in face-to-face, written, and telephone consultations. For example, an online consultation should include an explicit follow-up plan that is clearly communicated to the patient. In addition to the 12 guidelines stated earlier, the following are addi- tional considerations for fee-based online consultations: 1. Pre-Existing Relationship Online consultations should occur only within the context of a previ- ously established doctor–patient relationship that includes a face-to- face encounter when clinically appropriate. Informed Consent Prior to the online consultation, the health care provider must obtain the patient’s informed consent to participate in the consultation for a fee. The consent should include explicitly stated disclaimers and service terms pertaining to online consultations. The consent should establish appropriate expectations between provider and patient. Medical Records Records pertinent to the online consultation must be maintained as part of, and integrated into, the patient’s medical record. Fee Disclosure From the outset of the online consultation, the patient must be clearly informed about charges that will be incurred and that the charges may not be reimbursed by the patient’s health insurance. If the patient chooses not to participate in the fee-based consultation, the patient should be encouraged to contact the provider’s office by phone or other means. Appropriate Charges An online consultation should be substantive and clinical in nature and be specific to the patient’s personal health status. There should be no charge for online administrative or routine communications such as appointment scheduling and prescription refill requests. Health care providers should consider not charging for follow-up questions on the same subject as the original online consultation. Identity Disclosure Clinical information that is provided to the patient during the course of an online consultation should come from, or be reviewed in detail by, the consulting provider, whose identity should be made clear to the patient. Available Information Health care providers should state, within the context of the consulta- tion, that it is based only on information made available by the patient to the provider during or prior to the online consultation, including referral to the patient’s chart when appropriate and, therefore, may not be an adequate substitute for an office visit. Online Consultation vs Online Diagnosis and Treatment Health care providers should attempt to distinguish between online consultation related to pre-existing conditions, ongoing treatment, follow-up question related to previously discussed conditions, and so forth, and new diagnosis and treatment addressed solely online. New diagnosis and treatment of conditions, solely online, may increase liability exposure. The following copyright information is provided to users of the guidelines: Copyright © 2002 Medem, Inc. As patient–physician communication online expands, the standards of care and service will evolve. It is conceivable that, in the not-too- distant future, the use of online communication will become as com- monplace as the use of the telephone and there will be generally accepted norms for availability of clinicians to patients.

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