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-   -   Need explanation to this question? (https://www.usmle-forums.com/usmle-step-2-ck-forum/9336-need-explanation-question.html)

kemoo 05-17-2011 11:13 PM

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

anatomie 05-19-2011 05:37 AM

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 :(

healer2b 05-19-2011 08:23 AM

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.

MTBCK 05-19-2011 08:35 AM

Hey I too remember this question from NBME. Can anyone give the right answer and explanation to this?

Dr.kaushik 05-19-2011 08:39 AM

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...

healer2b 05-19-2011 08:47 AM

Quote:

Originally Posted by Dr.kaushik (Post 41076)
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

drdminorc 08-18-2015 04:23 AM

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.

RSan11 08-18-2015 04:36 AM

Quote:

Originally Posted by kemoo (Post 40746)
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.

Adjstmntdisorder 11-05-2015 11:35 PM

Quote:

Originally Posted by kemoo (Post 40746)
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:)

Adjstmntdisorder 11-05-2015 11:38 PM

Quote:

Originally Posted by Adjstmntdisorder (Post 930826)

All the best for your exam:)

I'm quite embarrassed. Your post is from 2011. You've probably given the exam by now.


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