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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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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
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
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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
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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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submitted by โpeqmd(75)
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.