The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
A 38-year-old woman presents to her primary care physician with a complaint of bad dreams. The dreams started approximately 5 months ago, and they occur without any specific pattern. The patient has only a vague recollection of the dreams. She reports that some kind of harmful being frightens her during the dreams, but she is unable to provide a clear visual description of the events or the sequence of incidents in the dreams.
The patient says that her husband has recently noticed that she has been screaming and thrashing her arms about during her sleep on some nights. When he has told her about these episodes in the morning, she has thought that they occur on the same nights that she has the bad dreams.
Overall, she describes herself as well rested and says that she does not consume any caffeinated beverages before sleeping. She has not had any significant change in her sleep habits, and she denies any physical discomfort or change in the temperature or lighting in the room when she sleeps.
She says that she is not under exceptional stress but remarks that she feels under more pressure than usual because of managing her household with two children in grade school, as well as working full-time as an administrative assistant at a local business. She often feels rushed and arrives at work late after getting her children on the school bus. Sometimes she needs to finish work at home that she did not complete during her workday. Overall, however, she has not received any complaints about her work performance, and she is not concerned about being fired.
Throughout her life, she has not had sleep disturbances or nightmares, and she usually does not remember her dreams. The patient has no history of psychiatric conditions. She describes her mood as generally happy and her key relationships as all positive.
She has a history of chronic allergies, which manifest with nasal congestion and rhinorrhea. She has used various over-the-counter decongestants intermittently since she was in her early 20s. The patient has not sought medical attention for her allergies, and she does not know whether her symptoms have a seasonal pattern. However, she reports that she does not have any symptoms at times whereas other times she has so much nasal congestion that she uses approximately one tissue box per day, especially at work.
Lately, her symptoms have worsened, and she has been taking medication that she removed from its original packaging and placed in a sandwich bag so that it could fit in her purse. She does not recall the name of the medication but says that she usually buys whichever decongestant is on sale at the store.
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Cite this: Heidi Moawad. A 38-Year-Old Woman’s Screaming, Thrashing Alarms Her Husband - Medscape - Jan 24, 2023.