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