| | INSOMNIA
Doorway information about patient
The patient is a 45-year old man who comes to the clinic with insomnia
Vital signs
. Temperature : 37’C
. Blood pressure : 120/70 mmHg
. pulses : 80 /min
. Respiratory arte : 14 /min
Approach to the patient
Insomnia can occur as a primary disorder or as a manifestation of an underlying condition (eg, restless legs syndrome , generalized anxiety disorder). the diagnosis of insomnia requires 4 key findings:
. Difficulty initiating or maintaining sleep
. Impairment of daytime function
. Adequate opportunity for sleep(i.e., extended periods of time in bed without excessive noise or interruption)
Normal sleep latency ( the time for transition from full wakefulness to sleep )is < 20-30 minutes, and most patient with insomnia report sleep latency > 30 minutes (or periods of waking > 30 minutes in duration ) . How ever , patient estimators of sleep latency are imprecise , and the diagnosis should be based primarily on subjective finding rather than a numerical value of sleep latency.
Different diagnosis
Insomnia can be categorized as - short -tern- (< 3months ) or -chronic -(> 3months). Insomnia can also be characterized as -initial insomnia - (difficulty falling asleep ) or -terminal insomnia-(difficulty maintaining sleep or waking to early) . Initial insomnia is often associated with anxiety , poor sleep hygiene , or use stimulates , wheres terminal insomnia is often a manifestation of depression or alcohol abuse.
Lack of sleep without daytime drowsiness may be an indication of bipolar disorder. However , the amount of sleep an individual needs is variable and generally declines with age.
Insomnia must be distinguished form disorders in which the patient has adequate but -nonrestorative sleep- (eg , obstructive sleep apnea ), or- altered sleep schedule- (eg , circadian rhythm disorder)
HISTORY AND PHYSICAL EXAMINATION
Address quanta and quality of sleep , daytime symptoms , possible triggers(eg, food , caffeine ) ,and comorbid conditions (eg , thyroid disorder , chronic pain) .In addition , review patient’s sleep habits : when of they go to bed and wake uno , what of the do just before and after lying down , how often do they take naps , eft, A though history may take most encounter , but the physical examination is often brief.
History
History of present illness
. How long do you had insomnia ?
. Do you have problems falling asleep? staying asleep?
. How often do you have trouble sleeping ?
. How long dose it take to fall asleep?
. How much sleep of you get in a typical night ?
. Do you feel tired in the morning when you wake up?
. Do you feel tired during the day?
. How dose your lack of sleep affect your daytime function (eg,work, driving )?
. Have you taken any medications to help you sleep?
. Do you consume caffeine in the afternoon or evening ( in beverages [ eg, coffee, tea, colas] and foods [eg, chocolates])?
. Do you watch television in bed?
. DO you wake uno at night to urinate?
. Have you been under more stress recently?
. How is your mood ?
. Has anyone noticed if you move your legs while sleeping?
. Has anyone noticed tat you snore loudly or stop breathing for extended periods while sleeping?
Past medical history
. Have you been diagnosed with any otters medical conditions (eg,hypothyroidism, heart failure)?
. Do you have any conditions that cause chronic pain?
Medications / allergies
. Inquires about stimulants , psychoactive medications , glucocorticoids, weight loss medications, and over the conner energy supplements?
Social history
. Do you smoke? When did you start& how much do you smoke?
. Do you drink alcohol? How much & how often? Do you drink alcohol before you go to bed?
. Have you used recreational drugs?
Physical examination
General
. Note grooming , hygiene, alertness
. Body habits
HEENT
. Facial & upper airway structure ( short mandible , wide craniofacial base , or hypertrophy of pharyngeal tissue increases risk of sleep apnea)
Neck
. Palpate thyroid
lungs
. Auscultate for breathing sounds & adventitious sounds
heart
. Auscultate ofr murmurs, gallops , rubs
Extremities
. Look for edema or tremor
Psychiatric
. psychomotor activity
. Mood , affect
. cognition
Closing the encounter
Patient with insomnia often have significant affective distress and may have additional stressors that are impacting their quality of life . in light of this , much of the wrap-up discussion may focus on how the patient’s insomnia is affecting well-being , functional status , and social interactions.
it is often helpful to counsel patient to keep a daily “sleep dairy “ (eg , time going to bed , how long to fall asleep , number /duration of awakenings , estimated hours of sleep , daytime symptoms , dietary and exercise habits). Treatment is not tested as part of the USMLE Step 2 CS exam . however , you may be able to counsel the patient briefly on nonpharmacologic management of insomnia.
Diagnostic studies
The diagnosis of insomnia is based primarily on clinical features . However , a limited diagnostic workup may be needed for nay underlying medical condones tat might contribute to the symptoms. Diagnostic studies include:
. Fasting glucose or hemoglobin A1c
. TSH
. Liver function panel (if heavy alcohol intake )
. Sleep study/ polysomnography (if features of obstructive sleep apnea)
. Urine toxicology / drug screen
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2018/05/24 09:53pm 
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