NBME 5 question

[LuckiestOne]

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A 26 yr old man comes to the physician because 6 months Hx of losing conciousness when he laughs.He sleeps 12 to 14 hrs every night ,has vivid dreams and nightmares, and feels tired during the day.He was recently involved in a motor vehicle collision.Findings on physical exam are unremarkable.Which of the following is most likely Dx?

A-Absence seizures
B-Complex partial seizures
C-Major depressive disorder
D-Malingering
E-Narcolepsy
F-post traumatic stress disorder
G-Sleep apnea
H-Sleep terror disorder

The answer that was included with the pdf file had D as the answer. Now that's clearly not the answer... I put E in the beginning because there was a hint of hypnagogic/hypnopompic hallucinations as mentioned by the vivid nightmares and also because he loses conciousness with laughter.

What do you guys think the answer is? Thanks!

 

[Myxedema]

You're right, it's E.

 

[LuckiestOne]

Thank you, Myxedema

 

[SCME500]

You're right, it's E.

Sorry. I don't know the answer but it'not narcolepsy - loc!!!!

 

[Myxedema]

Sorry. I don't know the answer but it'not narcolepsy - loc!!!!

Signs and symptoms of narcolepsy:

• Overwhelming urge to sleep with chronic hypersomnia may occur during the day.
• Cataplexy occurs in 60% to 100% of patients with narcolepsy and is reported as a partial or complete loss of voluntary muscle control with preserved consciousness that is precipitated by a strong emotion, more commonly with laughter. This is the most specific symptom and is considered pathognomonic for narcolepsy.
• Hypnagogic (wake to sleep) or hypnopompic (sleep to wake) hallucinations have been reported in 60% to 80% of patients with narcolepsy.
• Sleep paralysis, defined as loss of muscle tone during the transition between sleep and wakefulness, occurs in 60% to 80% of patients with narcolepsy. It may occur with hallucinations and can be interrupted by sensory stimuli.
• Fragmented sleep is seen in 60% to 80% of narcolepsy patients and can often be mistaken for insomnia or other intrinsic sleep disorder.
• Other symptoms that have been reported in narcolepsy include automatic behavior or semipurposeful movements in 40% of patients and memory disturbance in 50% of patients

Question:

A 26 yr old man comes to the physician because 6 months Hx of losing conciousness when he laughs.He sleeps 12 to 14 hrs every night ,has vivid dreams and nightmares, and feels tired during the day.He was recently involved in a motor vehicle collision.Findings on physical exam are unremarkable.Which of the following is most likely Dx?

 

[thehundredthone]

Signs and symptoms of narcolepsy:
...partial or complete loss of voluntary muscle control with preserved consciousness

Question:
...losing conciousness when he laughs

That's what SCME500 is getting at.

 

[LuckiestOne]

Question:
...losing conciousness when he laughs

That's what SCME500 is getting at.

Couldn't losing conciousness be same thing as falling asleep? After all, we do lose conciousness when we sleep.. It's a tricky question because everything points to Narcolepsy as answer except the "losing conciousness" part.

I guess it could be seizure related too, but what type of seizure causes those sxs described?

 

[Myxedema]

Fair enough, but it doesn't fit anything else. There's nothing to support that this is malingering (what's the gain?).

 

[RedSoxSuck]

Fair enough, but it doesn't fit anything else. There's nothing to support that this is malingering (what's the gain?).

So the answer isn't Narcolepsy?

I took it online and i put Narcolepsy. However, according to the answer key (used to see where i F'ed up) says its D (Malingering) which does not make sense at all.

 

[Belleza156]

Putting way too much thought into this....of course its narcolepsy. Every single thing in the vignette points to it. LOC is bad wording because its rapid onset of REM, but close enough. It's not even legal for ppl w narcolepsy to drive, super dangerous.

Btw don't trust online answred keys they always have errors. You need to check the answers yourself. And go to old threads for those u can't figure out. Helps to type the exact question in Google, and at least 5-10 threads show up.

Sent from my PC36100 using SDN Mobile

 

[LuckiestOne]

Putting way too much thought into this....of course its narcolepsy. Every single thing in the vignette points to it. LOC is bad wording because its rapid onset of REM, but close enough. It's not even legal for ppl w narcolepsy to drive, super dangerous.

Btw don't trust online answred keys they always have errors. You need to check the answers yourself. And go to old threads for those u can't figure out. Helps to type the exact question in Google, and at least 5-10 threads show up.

Sent from my PC36100 using SDN Mobile

Thank you, I actually did, and lots of people were giving me mixed answers.

I trust SDN's intellect the most so I choose to ask for your opinion 😀

 

[Fuzuli]

Patients with narcolepsy do not lose consciousness during cataplexy. They also have insomnia, not long ours of sleep. Since the patient's symptoms are inconsistent with one another, malingering is possible.

 

[RedSoxSuck]

.