A 77-year-old female patient presents with increasing muscle ...

[moongchi]

A 77-year-old female patient presents with increasing muscle weakness and numbness in both lower legs over the last week. She presents using crutches and with her daughter for walking assistance.
 
  Patient had influenza 3 weeks ago and was treated with amantadine. The patient denies recent trauma. Current medications include beta blocker and ACE inhibitor. Denies use of tobacco or alcohol. On physical examination, the patient is alert and oriented x 3, afebrile, pulse 66, resps 16/min, BP 110/70. Neck: no JVD, no thyromegaly, no bruits over carotid arteries. Heart: regular rate and rhythm, no murmurs. Lungs are clear to auscultation. Abdomen is non-tender with no organomegaly. Extremities: Skin is pink, cool to touch, and intact bilaterally. Hand grip strength: 5/5 bilaterally. Biceps DTR +2/4 bilaterally. Left and right quadriceps muscle strength 4/5. Patella reflex: 1/4 bilaterally. Achilles reflex: 1/4 bilaterally. Ankle strength: R + 3/5 and L + 3/5. Sensation to pinprick and cotton ball intact in face and upper extremities and bilaterally equal. Sensation to pinprick and cotton ball decreased in feet bilaterally. Dorsalis pedis pulses +1/4 bilaterally. Negative Homan's and Babinski's sign. The following disorder(s) should be high priority in the differential diagnosis:
  A. Amyotrophic lateral sclerosis
  B. Guillain-Barr syndrome
  C. Polymyositis
  D. Multiple sclerosis

Question 2

Which of the following is/are diagnostic criteria for primary insomnia?
 
  A. The sleep disturbance is defined as difficulty initiating or maintaining sleep, or non-restorative sleep, for at least 1 month
  B. The disturbance does not occur during the course of another mental disorder
  C. The sleep disturbance or associated daytime fatigue causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
  D. All of the above

[Benayers]

Answer to Question 1

ANS: B
Guillain-Barr syndrome is an acute, rapidly progressive polyneuropathy that is often preceded by a virus, surgical procedure, or immunization. It is thought to have an immune etiology.

Symmetric weakness and paresthesias are the main symptoms. The weakness usually begins in the legs and then proceeds to the arms. In addition to motor symptoms, patients often complain of distal paresthesias and neuropathic pain. Over 50 develop respiratory involvement, which may require mechanical ventilation. Autonomic dysfunction can occur in severe cases and can be fatal. The maximal degree of weakness usually occurs in the first 2 to 3 weeks. Most patients will recover, but approximately 20 will have persistent disability (Aminoff & Kerchner, 2014). Amyotrophic lateral sclerosis (ALS) actually belongs to a group of motor neuron diseases and is characterized by mixed upper and lower motor neuron deficits. ALS is characterized by muscle weakness and atrophy, usually starting in the hands and then progressing randomly and asymmetrically. Other common symptoms include muscle cramps, fasciculations, spasticity, dysarthria, dysphagia, and increased DTRs.

Answer to Question 2

ANS: D
Rationale: Insomnia has a multitude of causes, including age, menopause, chronic illness, pain, stress, anxiety, depression, poor sleep habits, endocrine disorders, or medications. The DSM-5 criteria for primary insomnia are as follows (American Psychiatric Association, 2013):
1. The sleep disturbance is defined as difficulty initiating or maintaining sleep, or non-restorative sleep, for at least 1 month.
2. The sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
3. The sleep disturbance does not occur exclusively during the course of narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder, or a parasomnia.
4. The disturbance does not occur exclusively during the course of another mental disorder (e.g., major depressive disorder, generalized anxiety disorder, a delirium).
5. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.