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NBME 21 Answers

nbme21/Block 3/Question#41

A 75-year-old woman comes to the physician's office ...

Major depressive disorder

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This question is describing terminal insomnia, which is common either in MDD or normal aging. Out of those two MDD is the only thing in option choice. Plus, old age is a risk factor for MDD.

Even though the question does not describe 5 symptoms needed to diagnose MDD, MDD is the only logical choice.

hungrybox  excellent answer, thank you +2  

 +3  upvote downvote
submitted by hungrybox(431),

other answers:

  • narcolepsy: Associated with hypnogogic or hypnopompic hallucinations.
  • hypnoGO to sleep = night time hallucinations

  • paroxysmal nocturnal dyspnea: PNH is a hemolytic anemia. No signs of hemolytic anemia (hematuria, jaundice, dec. haptoglobin).

  • sleep apnea: Associated with obesity, loud snoring.

doingit21  narrowed down to MDD and restless leg then convinced myself that elderly are at higher risk for MDD than RLS. Is that valid reasoning? +1  
yb_26  Paroxysmal nocturnal dyspnea = breathless awakening from sleep, seen in left heart failure. It is not a paroxysmal nocturnal hemoglobinuria. +7  

 +2  upvote downvote
submitted by whoissaad(39),
  • "Since symptoms can increase in severity during the night, it could become difficult to fall asleep or return to sleep after waking up"

  • "RLS is one of several disorders that can cause exhaustion and daytime sleepiness, which can strongly affect mood, concentration, job and school performance, and personal relationships. Many people with RLS report they are often unable to concentrate, have impaired memory, or fail to accomplish daily tasks"

  • "RLS occurs in both men and women, although women are more likely to have it than men."

  • "the symptoms typically become more frequent and last longer with age".

Source: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Restless-Legs-Syndrome-Fact-Sheet

Everything in the stem points towards restless leg syndrome.

Plus I thought you need 5/9 of the SIG E CAPS to diagnose depression.

Someone please explain :)

 +1  upvote downvote
submitted by seagull(714),

Depression is very common in older populations, especially females. Common symptoms of depression include SIG E CAPS (including insomnia). THis question was very vague but depression was edged out because sleep apnea is more likely in overweight middle aged males.

I chose MDD: 1) terminal insomnia 2) Narcolepsy - common in young adults adolescents - also associated with daytime unexpected naps (after which the person feels fresh) despite normal nightime sleep. 3paroxysmal nocturnal dyspnea is one of the first signs of decompensated heart failure but the physical examination was normal that means no lung crackles. 3) periodic leg movements could be REM Phenomena where muscles are not paralysed during REM sleep. 4)In sleep apnea the patient has poor quality of sleep but doesn't awaken