Question of the Week # 357

357)  A 52 year old man is seen in your office for pain in his legs that bothers him during sleep. He describes these episodes as aching and painful tightness particularly, in his posterior calves. The pain is relieved by forcefully stretching his leg muscles in opposite direction. He experiences these at least for about 2 to 3 nights per week and interferes with his sleep. He works as a coach for the local high-school soccer team and is physically very active. He has no other past medical problems and enjoys healthy living. On examination, his blood pressure is 122/80. Oral mucosa re moist.  There are no focal neuroligical deficits. Extremities appear normal with out any deformity, swelling or palpable tenderness. Peripheral pulses are normal. Serum electrolytes, Calcium, magnesium , a complete blood count, thyroid stimulating hormone and blood glucose are all within normal limits.  Which of the following is the most appropriate next step in managing his problem?

A) Start Ropinirole

B) Start Bromocriptine

C) Recommend non-pharmacological measures

D) Quinine Trial

E) Oral Iron Trial

10 Responses

  1. c

  2. E

  3. a
    this is restless leg syndrome

  4. A

  5. C) Recommend non-pharmacological measures – Nocturnal leg cramps

  6. e

  7. ~E.
    Iron therapy

  8. Patient is exhibiting restless leg syndrome (symptoms worse in the evening/night). The most commonly associated medical condition is iron deficiency but since his CBC is normal, we could go straight to dopamine agonists for treatment. Pramipexole is preferred over ropinirole.

    Answer A.

  9. Is the answer E)

    Nocturnal Leg Cramps Vs Restless Leg syndrome
    NLC : painful , sudden contractions , mainly posterior compartment of calf, U/L, awakens the patient from sleep and relieved by forcefully stretching the painful muscles

    RLS : discomfort or urge to move legs,Hallmark : sense of unease and weariness in lower legs that is relieved by leg movements. Described as ‘crawling’, ‘pulling’, ‘searing’ and ‘drawing’ sensation by the patient. Pain is NOT a feature of RLS

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