nbme test 4 for discussion 3 - drmaafo

[ArchivalUser]

An 83-year-old retired laboratory assistant is brought to the office by his daughter. She says, "He has suddenly become confused and doesn't remember things in just 1 week! Something's wrong." The patient's wife was admitted to the hospital 2 weeks ago because of a hip fracture. Currently she is at a neighboring rehabilitation facility for a 3-week stay to improve independent ambulation. The daughter traveled from out-of-state to live with her father while her mother is in rehabilitation. Screening blood tests are ordered; his rapid plasma reagin test is positive. Which of the following is the most appropriate step to assess whether the patient's mental status change is acute or chronic?

A ) Arrange for consultation with a neurologist
B ) Check his response to empiric therapy with ginkgo biloba
C ) Check his serum anti treponemal antibody titer
D ) Interview his family and friends more extensively
E ) Order an MRI of the brain

[ArchivalUser]

Go with C)

RPR and VDRL are 75 - 80 % sensitive in detecting primary syphilis.
1) if RPR + then VDRL - another antigen test, there are also others.
2) FTA - ABS - specific treponemal test - fluorescent treponemal antibody absorption. You take serum to do this.

Source: Internal Medicine CCS for USMLE Step 3 C Fischer book.

Let's do some more of these, if you 'd like.
vesodoc

Peace
V

[ArchivalUser]

if it asked me for a confirmatory test, I would say C. This patient has acute dementia. There are many causes, like for example UTI. I would like to get a better history of the patient to differentiate if its a chronic cause or acute. In neurosyphilis, the dementia is a chronic type-presents in late stages. Since this patient had a hip surgery recently, and is on bed rest, i would think he probably got an infection-therefore resulting in acute dementia.

[ArchivalUser]

Ok, ok.
Tertiary syphilis wouldn't lead to acute worsening of the mental state, as described.
MRI could show some process, or hemorrhage, although CT scan would be way better.
More history would be better to have too, although it's there in the words of the daughter, that it happened over a week. I agree it's confusing...