A 55-Year-Old War Veteran Comes to the Office Due to New

question 156

Multiple Choice

A 55-year-old war veteran comes to the office due to new onset of bizarre behavior that has occurred during sleep at night over the past 3 months.  His wife reports that he screams as if being attacked and swings his arms wildly while still asleep.  The patient has knocked over lamps on the bedside table and has hit his wife several times, once leading to a black eye.  He also hurt himself once by falling out of bed.  He is able to describe his dreams vividly and says they normally involve fighting with animals; he is completely lucid on awakening.  The patient snores loudly, but his wife has never seen him stop breathing during his sleep and he has not awakened gasping for breath.  When he was in the military 20 years ago, he was involved in a firefight during which a close army friend was shot and killed next to him.
Other medical issues include recently diagnosed depression, hypertension, and hyperlipidemia.  Current medications include hydrochlorothiazide, metoprolol, simvastatin, and venlafaxine.
Vital signs are normal.  BMI is 32 kg/m².  Physical examination is essentially normal except for a mild resting tremor.
Which of the following is the most likely diagnosis?

• A)Narcolepsy
• B)Obstructive sleep apnea
• C)Post-traumatic stress disorder
• D)REM behavior disorder
• E)Sleepwalking

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Definitions:

Calcium Ion Concentration

The level of calcium ions (Ca2+) in a particular system, important for various cellular processes including signal transduction and muscle contraction.

Parathyroid Glands

Small endocrine glands in the neck that produce parathyroid hormone (PTH), which regulates calcium levels in the blood.

Fight-or-Flight Response

A biological response triggered by the perception of danger, hostility, or a threat to one's existence.

Secondary Sex Characteristics

Changes that develop during puberty; in males, include growth of facial and body hair, muscle development, and the increase in vocal cord length and thickness that causes the voice to deepen; in females, include development of the breasts, broadening of the pelvis, and the development and distribution of muscle and fat responsible for the female body shape.