Need explanation to this question? - USMLE Forums
USMLE Forums Logo
USMLE Forums         Your Reliable USMLE Online Community     Members     Posts
Home
USMLE Articles
USMLE News
USMLE Polls
USMLE Books
USMLE Apps
Go Back   USMLE Forums > USMLE Step 2 CK Forum

USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam


Reply
 
Thread Tools Search this Thread Display Modes
  #1  
Old 05-17-2011
kemoo's Avatar
USMLE Forums Guru
 
Steps History: 1+CK+CS
Posts: 378
Threads: 161
Thanked 103 Times in 52 Posts
Reputation: 117
Question Need explanation to this question?

A 77-year-old woman is brought to the physician by her son for a routine health maintenance examination. She says that she feels well. Her son reports that 1 month ago, she got lost while driving home from the local supermarket. Two weeks ago, she forgot to turn off the stove after cooking dinner. She has been wearing bilateral hearing aids since audiometry 2 years ago showed bilateral high-frequency hearing loss. Her visual acuity corrected with glasses is 20/25 in both eyes. Neurologic examination shows mild fine tremors of the hands when the arms are outstretched; the tremor is not present at rest. Muscle strength is 5/5 in all extremities. Deep tendon reflexes are decreased at the ankles and 2+ elsewhere. Her gait is normal. Sensation to vibration is mildly decreased over the toes. On mental status examination, she is awake, alert, and conversant. Her language function is normal. She is oriented to person, place, and time and recalls one out of three objects after 10 minutes. Which of the following findings in this patient warrants further evaluation?

A) Decreased deep tendon reflexes at the ankles
B) Decreased sensation to vibration over the toes
C) High-frequency hearing loss
D) Memory loss
E) Tremor of the outstretched hands
Reply With Quote Quick reply to this message



  #2  
Old 05-19-2011
USMLE Forums Scout
 
Steps History: 1+CK+CS
Posts: 67
Threads: 24
Thanked 18 Times in 12 Posts
Reputation: 28
Default

this scenario has many distracters but also some key findings; i will give my opinion but i really don't know if it's a good one.....

from my first read i think this is a scenario of dementia.....from this point, there a quite a few causes which could get dementia:

1. at her age Altzheimer disease might be the very first choice; the problem is with the history: she got lost and forget to turn off the stove only one time.....there is no history of gradually worsening of those symptoms; in my opinion this is not the diagnosis here.
2. normal pressure hydrochepalus......in the scanario it says she has a normal gait and they don't say anything about urinary incontinence; so i think this is not the diagnosis also.
3. Parkinson disease.....her gait is normal but she has that mild tremor which is bilateral; as long as i remenmber, Parkinson disease starts unilateral and ussually occures at rest and improves with activity; here the patient has it when she outstratches the hands and is not present at rest....so i think this is not the right diagnosis also
4. hyperthyroidism.....besides that fine tremor, there is nothing else which could say that this is the right diagnosis.
5. from my point of view, the most important clues to the right diagnosis are the lost of vibration on her toes, decreased DTR's at the ankles and recalling only 1 word out of 3; in my opinion she has vitamin B12 deficiency which would explain most of the symptoms(memory loss=she got lost and forgot to turn off the stove, sensation lost=subacute combined degeneration of the spinal cord-partial explanation because her motor activity is 5/5 all over); so, in my opinion i would check first her serum B12 level and i would focus on that decreased sensation to vibration over the toes(answer B)

her hearing loss and 20/25 vision acuity, even though are not normal, are frequently seen at her age group without any other associated pathology;

again, this is my opinion and i might be wrong; it would be nice if somebody could post the right answer and give some explanations.....i think this is a hard/tricky question
Reply With Quote Quick reply to this message
  #3  
Old 05-19-2011
USMLE Forums Addict
 
Steps History: 1+CK+CS
Posts: 132
Threads: 11
Thanked 185 Times in 70 Posts
Reputation: 195
Default

Is this an NBME question? I remember seeing it before.

Personally I don't think it's worth losing much sleep over it. I don't completely understand what they are getting at. I'm pretty sure decreased ankle reflexes are a very normal part of aging.
Reply With Quote Quick reply to this message
 
  #4  
Old 05-19-2011
USMLE Forums Scout
 
Steps History: 1 + CS
Posts: 12
Threads: 2
Thanked 12 Times in 4 Posts
Reputation: 22
Default

Hey I too remember this question from NBME. Can anyone give the right answer and explanation to this?
Reply With Quote Quick reply to this message
  #5  
Old 05-19-2011
Dr.kaushik's Avatar
USMLE Forums Addict
 
Steps History: Step 1 Only
Posts: 100
Threads: 35
Thanked 7 Times in 7 Posts
Reputation: 17
Default

why not A be the answer??.....DTR is more valuable to physician...patients age is 77 ....Vibration sense is subjective.....
peripheral neuropathy should be suspected....causes both decrease vibration, decreased DTR....
though not sure..
senile dementia and HF hearing loss common at such age...
Reply With Quote Quick reply to this message
  #6  
Old 05-19-2011
USMLE Forums Addict
 
Steps History: 1+CK+CS
Posts: 132
Threads: 11
Thanked 185 Times in 70 Posts
Reputation: 195
Default

Quote:
Originally Posted by Dr.kaushik View Post
why not A be the answer??.....DTR is more valuable to physician...patients age is 77 ....Vibration sense is subjective.....
peripheral neuropathy should be suspected....causes both decrease vibration, decreased DTR....
though not sure..
senile dementia and HF hearing loss common at such age...
Because decreases ankle reflexes are quite normal in the elderly. I don't have time to find a good source to validate that, but I did find the following, which echoes what I have been taught in my clinical rotations:

BIOLOGICAL ASPECT OF AGING

Individuals are unique in their psychological and physical aging process. As the individual ages, there is a quantitative loss of cells and changes in many of enzymatic activities within cells resulting in a diminished responsiveness to biological demands made on the body. Age related a change occurs at different rate in different people.

NERVOUS SYSTEM

The brain atrophies as a result of aging process. The brain weight decreases, decrease in enzymes, protein and lipids in brain tissue.
There is shrinkage of large neurons resulting in loss of large neurons with an increase in smaller neurons.
There is alterations in the amount for some neuro-transmitters.
Clinical changes due to the above are decreased sensation of vibrations(particularly in legs), less brisk deep tendon reflexes with ankle reflex absent entirely and a decreased ability for upward gaze.
Functional changes include slowing of response to tasks and the increase in time to recover from physical exertion
Cognitive changes include memory loss, decrease in perceptual ability and decrease in proficiency.

Quoted from http://nursingplanet.com/nr/blog5.ph...-aging-process
Reply With Quote Quick reply to this message
The above post was thanked by:
blackychen (10-09-2015), Dr.kaushik (05-19-2011)
  #7  
Old 08-18-2015
USMLE Forums Scout
 
Steps History: Not yet
Posts: 19
Threads: 0
Thanked 7 Times in 4 Posts
Reputation: 17
Default

I've answered Tremors with outstreched hands thinking that it might be something sinister regarding cerebellum. Needless to say I was wrong.

I believe the answer should be memory loss for the following reasons:
1. Age= She is 70+
2. Lifestyle impairment = She got lost while shopping and forgot to turn off the stove

With the above mentioned points we should suspect Alzheimer's or other causes of dementia in general.

Loss of DTRs at ankles is normal part of aging as per Uworld Step 2 CK. Same can be said about decreased vibratory sensation.
High frequency hearing loss is part of normal aging called presbycusis if i'm not mistaken.
And last but certainly not the least, tremors could be explained as essential tremors. The description of tremors does match cerebeLLUM disorders but the fact that I got it wrong would mean that it could be less sinister.

Hope this helped.
Reply With Quote Quick reply to this message
  #8  
Old 08-18-2015
RSan11's Avatar
USMLE Forums Scout
 
Steps History: Not yet
Posts: 36
Threads: 14
Thanked 2 Times in 2 Posts
Reputation: 12
Default

Quote:
Originally Posted by kemoo View Post
A 77-year-old woman is brought to the physician by her son for a routine health maintenance examination. She says that she feels well. Her son reports that 1 month ago, she got lost while driving home from the local supermarket. Two weeks ago, she forgot to turn off the stove after cooking dinner. She has been wearing bilateral hearing aids since audiometry 2 years ago showed bilateral high-frequency hearing loss. Her visual acuity corrected with glasses is 20/25 in both eyes. Neurologic examination shows mild fine tremors of the hands when the arms are outstretched; the tremor is not present at rest. Muscle strength is 5/5 in all extremities. Deep tendon reflexes are decreased at the ankles and 2+ elsewhere. Her gait is normal. Sensation to vibration is mildly decreased over the toes. On mental status examination, she is awake, alert, and conversant. Her language function is normal. She is oriented to person, place, and time and recalls one out of three objects after 10 minutes. Which of the following findings in this patient warrants further evaluation?

A) Decreased deep tendon reflexes at the ankles
B) Decreased sensation to vibration over the toes
C) High-frequency hearing loss
D) Memory loss
E) Tremor of the outstretched hands
I would select D, because remembering one out of 3 in 10 minutes is not something age-related.
Reply With Quote Quick reply to this message
  #9  
Old 11-05-2015
USMLE Forums Scout
 
Steps History: 1 + CK
Posts: 19
Threads: 3
Thanked 5 Times in 5 Posts
Reputation: 15
Default

Quote:
Originally Posted by kemoo View Post
A 77-year-old woman is brought to the physician by her son for a routine health maintenance examination. She says that she feels well. Her son reports that 1 month ago, she got lost while driving home from the local supermarket. Two weeks ago, she forgot to turn off the stove after cooking dinner. She has been wearing bilateral hearing aids since audiometry 2 years ago showed bilateral high-frequency hearing loss. Her visual acuity corrected with glasses is 20/25 in both eyes. Neurologic examination shows mild fine tremors of the hands when the arms are outstretched; the tremor is not present at rest. Muscle strength is 5/5 in all extremities. Deep tendon reflexes are decreased at the ankles and 2+ elsewhere. Her gait is normal. Sensation to vibration is mildly decreased over the toes. On mental status examination, she is awake, alert, and conversant. Her language function is normal. She is oriented to person, place, and time and recalls one out of three objects after 10 minutes. Which of the following findings in this patient warrants further evaluation?

A) Decreased deep tendon reflexes at the ankles
B) Decreased sensation to vibration over the toes
C) High-frequency hearing loss
D) Memory loss
E) Tremor of the outstretched hands
I agree. the answer is D.
Forgetting your way back home and leaving the stove off once, poor 3 word recall test indicates deterioration in executive functions and is the typical initial episodic memory loss seen in Alzheimer's.

Tremor of the outstretched hands. . . Does sound like hyperthyroidism but there is no other feature. Besides hypothyroidism is a cause of dementia not hyper. It could be placed there just to confuse.

The other options are wrong because such changes are common above 77 years. I think I read that in UWorld.

All the best for your exam
Reply With Quote Quick reply to this message
  #10  
Old 11-05-2015
USMLE Forums Scout
 
Steps History: 1 + CK
Posts: 19
Threads: 3
Thanked 5 Times in 5 Posts
Reputation: 15
Default

Quote:
Originally Posted by Adjstmntdisorder View Post

All the best for your exam
I'm quite embarrassed. Your post is from 2011. You've probably given the exam by now.
Reply With Quote Quick reply to this message



Reply

Tags
Neurology-, Step-2-Questions

Quick Reply
Message:
Options

Register Now

In order to be able to post messages on the USMLE Forums forums, you must first register.
Please enter your desired user name, your email address and other required details in the form below.
User Name:
Password
Please enter a password for your user account. Note that passwords are case-sensitive.
Password:
Confirm Password:
Email Address
Please enter a valid email address for yourself.
Email Address:
Medical School
Choose "---" if you don't want to tell. AMG for US & Canadian medical schools. IMG for all other medical schools.
USMLE Steps History
What steps finished! Example: 1+CK+CS+3 = Passed Step 1, Step 2 CK, Step 2 CS, and Step 3.

Choose "---" if you don't want to tell.

Favorite USMLE Books
What USMLE books you really think are useful. Leave blank if you don't want to tell.
Location
Where you live. Leave blank if you don't want to tell.

Log-in

Human Verification

In order to verify that you are a human and not a spam bot, please enter the answer into the following box below based on the instructions contained in the graphic.



Thread Tools Search this Thread
Search this Thread:

Advanced Search
Display Modes


Similar Threads
Thread Thread Starter Forum Replies Last Post
question help: diabetic foot related question dezirablize USMLE Step 2 CK Forum 5 01-15-2015 02:42 PM
sensitivity and specificity question? need explanation kemoo USMLE Step 1 Forum 5 03-30-2011 08:51 AM
Explanation of the Narcolepsy features? kemoo USMLE Step 1 Forum 2 03-27-2011 02:31 AM
Should we read the explanation for questions we answered right? mahganem USMLE Step 1 Forum 3 10-14-2010 07:13 PM
simple explanation Seetal USMLE Step 1 Forum 4 08-31-2010 07:59 AM

RSS Feed
Find Us on Facebook
vBulletin Security provided by vBSecurity v2.2.2 (Pro) - vBulletin Mods & Addons Copyright © 2017 DragonByte Technologies Ltd.

USMLE® & other trade marks belong to their respective owners, read full disclaimer
USMLE Forums created under Creative Commons 3.0 License. (2009-2014)