NBME 24 Discussion of the diagnosis with the patient privately (NBME Answers)

NBME 24 Answers

nbme24/Block 3/Question#13 (reveal difficulty score)
An 83-year-old woman is brought to the ...
Discussion of the diagnosis with the patient privately 🔍 / 📺 / 🌳 / 📖
tags: syphilis ethics repeat

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submitted by ∗peqmd(74)

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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.

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submitted by centeno(3)

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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.

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j44n The maximum MMSE score is 30 points. A score of 20 to 24 suggests mild dementia, 13 to 20 suggests moderate dementia, and less than 12 indicates severe dementia. On average, the MMSE score of a person with Alzheimer's declines about two to four points each year. she only has mild dementia. I had to look this up she could still retain her capacity +1

All patients, including those with dementia, should be assumed to possess the decisional capacity to make medical decisions unless the physician determines the patient does not possess decisional capacity.

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submitted by ∗lispectedwumbologist(122)

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Can anybody explain this one? I put repeated tests because I assumed an 83-year-old woman is an unusual demographic for syphilis.

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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. +5

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. +4

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. +12

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. +12

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 +14

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

imtiredofstudying the entire point of this question is that when you see an STD in an unexpected demographic (children, elderly), THINK SEXUAL ABUSE +

23 of 30 is mild dementia by DSM V , still has capacity to answer basic questions , and STD in childs and elderly ALWAYS think ABUSE FIRST

+2/- usmlecrasherss(27)

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submitted by ahd_ve(7)

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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

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submitted by komodo(4)

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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)

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submitted by ∗deathbystep1(21)

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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!!!

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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. +2

saturdaynightpalsy To add to that, I didnt choose the other answers you listed for the same reasons you listed. +1

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. +1

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 +3

cbreland Are we expected to interpret MCI scores +

madamestep Mild memory impairment does NOT mean decreased decision-making capacity. An 83 year old with an almost normal mental status exam who maybe has a new boyfriend at her nursing home probably wouldn't want her daughter to know that she has an STI. And if this is elder abuse, you'd also want to talk to her privately to see if she's safe. No matter what, older adults with mild dementia are still normal people and you need to assess their decision-making capacity decision to decision. This woman most likely has the capacity to decide if she wants to undergo syphilis treatment. +

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