M.T. Hughes 1 ; 1 Johns Hopkins University, Baltimore, Maryland LEARNING OBJECTIVES: 1. Assess the role of weak paternalism for patients lacking decision-making capacity, when no readily identifiable surrogate decision-maker is available. 2. Weigh the obligations of beneficence, respect for autonomy, and an ethic of care. 3. Determine the goals of care for cognitively impaired patients with a life-limiting illness. CASE INFORMATION: 82 year old male with multiple medical problems including coronary artery disease, severe chronic obstructive pulmonary disease, and moderate, multi-factorial dementia presented with poor appetite after being lost to medical follow up for six months. Previous physicians had prescribed megestrol for anorexia. Left renal mass had been detected five years earlier and``watchful waiting'' approach had been arranged with urologist two years prior to presentation. Six months prior to presentation, CT scan demonstrated enlargement of mass and findings consistent with renal cell carcinoma. Patient had been referred back to urology but appointment did not occur. Over course of current evaluation, when asked whether to pursue repeat CT scan, patient stated,``It don't bother me, so don't bother with it.'' Patient lived with his 84 year old wife, who likewise had moderate dementia and had recently undergone surgical resection of Stage III gastric carcinoma. Patient had lost contact with distant cousins in another state and denied any other family members who could help with decision-making. His day consisted of "chewing the fat" with friends at the local market. He enjoyed his life and wanted to stay at home with his wife as long as he could. CT scan and urology consultation were not pursued. One year later, the patient suffered a major stroke. Home hospice was arranged, but his wife was unable to care for him at home. On presentation to the emergency room, she had no recollection of his stroke and no recognition of his dense hemiplegia. The patient was transferred to an inpatient hospice, where he died two weks later. His wife underwent psychiatric hospitalization for her dementia and was subsequently transferred to an assisted living facility. DISCUSSION: Informed consent rests upon the principle of respect for autonomy and thus requires voluntariness and competence. This patient had impaired judgment, poor recall, and an inability to comprehend complex information. Informed consent was not possible. His wife lacked decision-making capacity. Together, both could live independently in the community, compensating for each other's deficits. Neither could weigh the benefits and burdens of a major surgery. In acting out of beneficence, the physician in this case needed to determine whether definitive treatment for the renal mass (nephrectomy with significant perioperative risk) was a benefit or a harm. Goal setting and understanding the patient as person resulted in a decision that did not strictly adhere to an autonomy model. An ethic of care, focusing on maintenance of the relationship between husband and wife, was judged to be more determinative than a principle-based ethic. This case demonstrates that in certain well-defined situations, the physician may be justified in invoking weak paternalism.`P ANCREATITIS, HEPATITIS, AND DERMATITIS'' IN A 70 YEAR OLD FEMALE. L. Humphreys 1 , E. Yee 1 , A. Gomez 1 ; 1 UCLA San Fernando Valley Program, Sepulveda, Ca LEARNING OBJECTIVES: 1) Recognize the clinical presentation of dermatomyositis, 2) Discuss the work up and treatment of dermatomyositis, 3) Discuss screening for occult malignancies associated with dermatomyositis. CASE INFORMATION: A 70 yo Latina female with a history of cholecystectomy presented with 3 days of nausea, vomiting, and epigastric pain. She denied fever, chills, diarrhea and constipation. She took no medications and denied ETOH use. She was a thin female with T 36.1 C, BP 96/52, P 68, R 18. A violaceous rash was present on her forehead, eyelids, and nose. She had epigastric tenderness with guaiac negative stool. Extremities had subcutaneous calcifications with diffuse weakness proximally. Lab work was remarkable for AST 842, ALT 467, T bili 1.3, D bili 0.3, Alk Phos 352, lipase 9,759, and serial CK's of 5640, 4811, 3835. EKG was normal and troponin negative x 2. An U/S showed no biliary dilation, gallbladder, or stones, and a poorly visualized pancreas. She was hospitalized with the presumptive diagnosis of "pancreatitis, hepatitis, and dermatitis". Subsequent workup found normal triglyceride and calcium levels, negative viral hepatitis serologies, and an unremarkable abdominal CT scan. An elevated aldolase of 24.9, EMG with myopathic changes, and muscle biopsy demonstrating myositis confirmed the diagnosis of dermatomyositis. She improved clinically with steroids. Work up for occult malignancy including CXR, PAP smear, mammography, CA-125 level, endoscopy, and colonoscopy were all normal. An etiology for her pancreatitis was never found. DISCUSSION: Dermatomyositis (DM) is an idiopathic inflammatory myopathy that usually presents with proximal muscle weakness. Distinctive skin manifestations include a psoriatic rash over the knuckles (Gottron's papules), periorbital discoloration (heliotrope rash), and subcutaneous calcifications. DM occurs in approximately 5/1,000,000 people. Diagnosis is confirmed by elevated muscle enzymes, myopathic EMG findings, and muscle inflammation on biopsy. Presence of anti-Mi-2 antibody is specific for DM, but is found in only 25% of cases. First line therapy is systemic corticosteroids, with methotrexate, azathioprine, or cyclophosphamide reserved for refractory cases. Malignancy occurs between 7% and 34% in DM patients, with ovarian and colon cancers found most often. Cancer associated disease is more common in older patients and is associated with a worse prognosis. There may be a delay of up to five years before any associated malignancy develops. Although this patient had an extensive workup because of her symptoms, asymptomatic patients with DM should routinely undergo age specific screening tests for occult malignancies. LEARNING OBJECTIVE: To recognize the early signs of cerebral aneurysms and make an early diagnosis CASE INFORMATION: 59-year-old male with history of well controlled hypertension and COPD presented with a severe headache 10/10 in intensity, throbbing, constant and gradual in onset which began 11 days ago in the occipital area and then extended to the right temporal/ posterior orbital area. Two days prior to admission he started having diplopia, ataxia and nausea/vomiting. The patient denied fevers, chills, photophobia, phonophobia, neck stiffness, numbness, weakness, vertigo or seeing flashing lights. Past surgical history includes splenectomy after gun shot wound in 1965. Patient also with history of polysubstance abuse, last used 2 years ago. Family history is non-contributory. On initial examination blood pressure was 167/90, temperature 36.5, heart rate 72 and respiratory rate 18. The patient was alert and oriented and in no acute distress but did report a 10/10 headache. Eye examination was significant for a right pupil which was 5 mm and sluggish to react as opposed to a left pupil which was 2 mm and reactive. There was ptosis of the right eyelid, a deficit in medial and upward gaze on the right and a deficit in accommodation on the right side. There was no papilledema and pressures were 12 bilaterally. Visual acuity was normal and equal bilaterally. The neck was supple and there were no carotid bruits. Neurologically there were no other cranial nerve deficits and no other neurological deficits. CBC and chem.-7 were normal and patient had an ESR of 10. The patient had an MRA which confirmed the diagnosis of posterior communicating artery aneurysm compressing the third cranial nerve. The patient was then transferred to neurosurgery and underwent clipping of the aneurysm. DISCUSSION: 90%of all intracranial aneurysms are congenital. Common locations include: anterior communicating artery, bifurcation of the middle cerebral artery, posterior communicating artery, internal carotid artery bifurcation and the basilar circulation. Unruptured aneurysms are usually < 6±7 mm and 20% of patients present with oculomotor nerve palsy. These patients usually have aneurysms of the internal carotid artery at the posterior communicating artery. Rupture most commonly causes subarachnoid hemorrhage. Symptoms of rupture include sudden severe headache, altered mental status, meningeal irritation, vomiting, diaphoresis, fever, focal neurological deficits, seizures and visual changes (diplopia, homonymous hemianopsia, miosis or mydriasis). The incidence of sudden death is greatest in the first week. Potential complications include rebleeding, cerebral swelling, hydrocephalus, and infarction secondary to vasospasm. The diagnosis can be confirmed with lumbar puncture where the CSF will show red blood cells, low glucose, elevated protein and a pressure usually > 150. A CT is also useful in detecting aneurysms > 5 mm, subarachnoid blood, infarction and edema. MRA is more sensitive and detects 80% or aneurysms. The treatment is usually surgical but medical therapy can be used to delay surgery and is surgery is contraindicated. Medical therapy includes lowering of blood pressure, bed rest, steroids, anticonvulsants and antifibrinolytic agents. year-old male presented with a one week history of abdominal pain, nausea, and vomiting. The night prior to presentation, he was noted to be disoriented and lethargic. Several hours later, he was febrile and diaphoretic and was taken to the hospital. On physical exam, he was alert and responsive. His BP was 70/36, heart rate 132, respiratory rate 40, and temperature 35 degrees celsius. Significant findings also included edematous sclerae with petechiae, diffuse rales, a distended abdomen, and diffuse purpura over his extremities. ABG revealed a pH of 7.08, pCO 2 of 71, pO 2 of 77, and bicarbonate of 20. His WBC was 25,600 (28% bands), platelet count 18,000, BUN 36, Cr 4.2, and INR 3.2 . Chest xray showed bilateral alveolar edema. Despite receiving several liters of saline, he continued to be hypotensive and became more hypoxemic, requiring intubation. His cardiac rhythm deteriorated to pulseless electrical activity from which he was successfully resuscitated. The diagnoses of septic shock, acute renal failure, disseminated intravascular coagulation, and adult respiratory distress syndrome (ARDS) were made. He was started on Penicillin G for suspected meningococcemia, dopamine, norepinephrine, continuous veno-venous hemodiafiltration (CVVHD), fresh frozen plasma and antithrombin III. His blood cultures grew Neisseria meningitidis. After 2 weeks, his renal function and coagulopathy resolved. His left lower extremity became ischemic and nonviable and was amputated. One week later he was discharged to a rehabilitation facility. DISCUSSION: Infections with Neisseria meningitidis range from mild upper respiratory infections to fulminant meningococcemia in 10±20% of cases. Few other diseases present as catastrophically as fulminant meningococcemia and prompt recognition and early treatment are crucial. Symptoms include sudden onset of fevers, chills, nausea, vomiting, and myalgias, progressing to shock and multisystem organ failure within hours. Purpura fulminans is present in 75% of patients, characterized as maculopapular or petechial lesions which can become hemorrhagic. In addition to antibiotics and coagulation factors, patients may also require ventilatory support. In order to remove toxic substances and cytokines, CVVHD is beneficial. The mortality rate with fulminant meningococcemia is as high as 50%, but with prompt recognition and treatment, up to 80% of patients can have favorable outcomes.