CASE 29 - Sleeping Problems

Question 1

Will I ever be able to sleep well again, doctor?

Answer 1

First we need to run some tests to r/o underlying medical problems.

In the meantime, I recommend some lifestyle changes. If you drink coffee, I strongly recommend that you cut down on your caffeine intake.

You could also benefit from exercising, preferably during the day and not right before bedtime. Finally, you should get into the habit of going to bed early—for example, at 10pm each night.

It would help if you went to sleep around the same time each night and woke up around the same time each morning. I would also encourage you to abstain from drinking alcohol several hours before bedtime.

Question 2

Specific questions:

Answer 2

1. Total hrs of sleep per night.
2. Time you fall asleep.
3. Activities before sleep.
4. Sleep interruptions.
5. Early spontaneous awakening.
6. Snoring — daytime sleepiness — daytime naps.
7. Recent stress/illness — depression.
8. Caffeine intake — tremors.
9. Thyroid + CV/chest stuff.

Question 3

PEx:

Answer 3

1. HEENT ==> I + P + A of thyroid for LAN.
2. CV ==> A.
3. Chest ==> A.
4. Abdo ==> I + A + P.
5. Extr ==> Checked for tremor on outstretched fingertips, looked for edema.
6. Skin ==> Inspection.
7. Neuro ==> Looked for brisk reflexes.

Question 4

DDx:

Answer 4

1. Anxiety.
2. Caffeine-induced insomnia.
3. Hyperthyroidism.
4. Insomnia due to depression.
5. Insomnia 2o to adjustment disorder.
6. Illicit drug use.
7. OSA.
8. Insomnia with circadian rhythm sleep disorder.
9. Daytime fatigue in 1o HYPERSOMNIA.
10. Insomnia with circadian rhythm sleep disorder.

Question 5

Workup:

Answer 5

1. TSH, FT3, FT4.
2. Urine toxicology.
3. CBC.
4. Polysomnography.
5. ECG.
6. Mental status exam.

Question 6

Insomnia due to depression:

Answer 6

Depression a/w

1. Sleep onset insomnia.
2. Maintenance insomnia.
3. Early morning wakefulness.

Question 7

Hypersomnia occurs in some depressed patients:

Answer 7

1. Especially adolescent and those with either bipolar or seasonal (fall/winter) depression.