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NBME 24 Answers

nbme24/Block 3/Question#13 (39.2 difficulty score)
An 83-year-old woman is brought to the ...
Discussion of the diagnosis with the patient privately🔍
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m-ice  83 might seem an uncommon age, but we don't know for sure her sexual history. She only recently (8 months ago) started showing some signs of mild cognitive impairment. She has all these results implying that she has syphilis, so the most likely answer is that she has syphilis, so we should speak to her privately about her sexual history. The tests don't necessarily means she got syphilis very recently, it's possible she's had syphilis for a while and never got treated. +4  
mousie  I understand that she could possibly have syphilis but I also put repeat tests because I know there are a few things that can cause false positive VRDLs but if she also has a + RPR does this make a FP less likely? And also if she has mild cognitive impairment you still discuss with her not her daughter correct ...? +4  
m-ice  This definitely could be a false positive, but before we want to consider it to be a false positive, we should talk to the patient about it privately. Assuming that it's a false positive before asking the patient about it could delay treatment of her syphilis. There's a chance she didn't want to disclose her sexual history in front of her daughter or maybe she was embarrassed or didn't think it was important to mention. And you're absolutely right, she only has mild cognitive impairment, so we most definitely should talk to the patient alone without her daughter first. +3  
seagull  She has dementia. She doesn't have the capacity to determine her own care (23/20 MME). I feel the daughter should have the word on the care since Grandma likely doesn't have the capacity to understand her actions. +5  
sajaqua1  From what I remember, dementia is typically a combination of impaired memory *and* impaired thought processes. There is nothing to indicate that the patient has impaired thought processes, and the memory impairment is only mild. The patient can still reasonably said to be competent, and so her private information should be discussed with her alone. +10  
yotsubato  Elder care homes or elderly communities actually have a high rate of STDs. Turns out, when you put a bunch of divorced/widowed adults together in a community they have sex. +7  
yotsubato  Additionally, you should respect the privacy of a competent adult with "Mild memory" impairment. I know I could have mild memory impairment considering the crap I forget studying for step 1 +10  
drdoom  @seagull dementia ≠ absence of competence -- the two are separate concepts and have to be evaluated independently. see https://meshb.nlm.nih.gov/record/ui?ui=D003704 and https://meshb.nlm.nih.gov/record/ui?ui=D016743 +3  
wowo  also important to note, d) repeated tests is also incorrect as the microhemagglutination assay is a confirmatory treponemal test (along the same lines as FTA-ABS) https://www.uofmhealth.org/health-library/hw5839 +5  
sunshinesweetheart  also.... I think we can assume that "repeated tests" means repeat VRDL, not "additional tests to rule out false positives" +2  



 +1  upvote downvote
submitted by peqmd(25),

question is asking what's the best next step not necessarily what is the best diagnostic step, which is somewhat of Step 2 rotation shelf question (for people who takes Step 1 after rotations). TLDR, best NEXT step is talk to her first at minimum you need to determine if she has capacity.

While the patient has pretty bad MMSE:

B. Is the best next step. You need to discuss with her first. => determine her decision making capacity => then proceed whether to discuss with her daughter (A).

Lumbar puncture is the best diagnostic step. However, in this question they're asking you what you need to do to even proceed to this step. I.e. get her capacity then you can proceed to lumbar. This is because lumbar puncture is more invasive and you'll need to assess capacity as well as get either her (if she has capacity) or daughter.




 +1  upvote downvote
submitted by gabfer92(1),

UWorld: Elder Abuse: Risk factors -Female; -Dementia, chronic mental ilness. Manifestations of abuse: Physical & Sexual abuse: Newly acquired STI, among others.




 +1  upvote downvote
submitted by centeno(2),

I thought that the cognitive impairment could be the manifestation of neurosyphilis. In addition, the doctor should talk directly to the patient to check for sexual abuse.




 +1  upvote downvote
submitted by ahd_ve(5),

the main goal for this question is avoid discussing issues with relatives without the patient’s permission. but some people were deeply shocked to see that a grandmother has syphilis. Btw I leave a link of a research about Clinical Utility of the Mini-Mental Status Examination When Assessing Decision-Making Capacity. https://journals.sagepub.com/doi/abs/10.1177/0891988709342727




 +0  upvote downvote
submitted by komodo(0),

I think one of the confusions here is that the microhemagglutination assay doesn't necessarily indicate current infection with syphilis, because treponemal tests can stay positive even for years after treatment (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2095002/) That in combo with the very low RPR titer could indicate treated syphilis. So really the best thing to do would be to ask the patient directly about it before you waste time doing possibly unnecessary testing (and I would definitely ask her directly since most people don't talk about their STIs with their children)




option B) (the correct option as per nbme) :the patient has a mini mental state of 23/30, so that should mean that she isn't capable of making her own decisions! so whats the point in talking to her privately without her daughter?

option A) is wrong because you cant just hide the diagnosis from the patient and share it with the family

option C & D)you cannot disregard the test or repeat the test as both the test are positive, RPR is a screening test with less specificity but microhemagglutination is a highly specific test so she definetly has syphillis!

option E) doesnt make sense because why would you do lumbar puncture for syphillis?!

i think they forgot to give an option F) just freakin treat her for syphillis!!!

saturdaynightpalsy  "Patients with suspected neurosyphilis should undergo lumbar puncture and subsequent VDRL, FTA-ABS and/or PCR of cerebrospinal fluid" per my notes and the internet Lumbar puncture is used to diagnose neurosyphilis, so that's what I put. +1  
saturdaynightpalsy  To add to that, I didnt choose the other answers you listed for the same reasons you listed. +  
ac3  which of the following is the NEXT BEST STEP meaning you wouldnt want to jump straight to a lumbar puncture especially when there are answer choices that suggest discussing the diagnosis with the patient first. If you went to the doctor and they diagnose you they will discuss this with you before ordering additional testing. +  
yerpderp  23/30 is also just mild cognitive impairment so I just thought she still had decision making capability as 24/30 is still normal +