Insomnia

Question 1

What key history would you obtain from a patient who complains of insomnia?

Answer 1

Primary vs. secondary
Duration
Description (trouble falling asleep, multiple awakenings, early morning awakending)
Snoring, nightmares
Depression
Caffeine use
Recreational drug use
Work or lifestyle (jet lag, shift work)
Stressors 
Sleep hygiene

Question 2

What key physical exams would you perform for someone who complains of insomnia?

Answer 2

Vital signs

Mental status exam

Question 3

25 yo F presents with a three week history of difficulty falling asleep. She sleeps seven hours per night without nightmares or snoring. She recently began college and is having trouble with her boyfriend. She drinks 3-4 cups of coffee a day. Differentials?

Answer 3

Stress-induced insomnia
Caffeine-induced insomnia
Insomnia with circadian rhythm sleep disorder
Insomnia related to major depressive disorder

Question 4

25 yo F presents with a three week history of difficulty falling asleep. She sleeps seven hours per night without nightmares or snoring. She recently began college and is having trouble with her boyfriend. She drinks 3-4 cups of coffee a day. Differentials: stress-induced insomnia, caffeine-induced insomnia, insomnia with circadian rhythm sleep disorder, insomnia related to major depressive disorder. Workup?

Answer 4

Polysomnography
Mental status exam
Urine toxicology
CBC
TSH

Question 5

55 yo obese M present with several months of poor sleep and daytime fatigue. His wife reports that he snores loudly. Differentials?

Answer 5

Sleep apnea
Daytime fatigue in primary hypersomnia
Insomnia with circadian rhythm sleep disorder
Insomnia related to major depressive disorder

Question 6

55 yo obese M present with several months of poor sleep and daytime fatigue. His wife reports that he snores loudly. Differentials: sleep apnea, daytime fatigue in primary hypersomnia, insomnia with circadian rhythm sleep disorder, insomnia related to major depressive disorder. Workup?

Answer 6

Polysomnography
CBC
TSH
ECG

Question 7

33 yo F complains of three weeks of fatigue and trouble falling asleep easily but wakes up at 3 am and cannot return to sleep. She also reports an unintentional weight loss of 3.5 kg along with an inability to enjoy the things she once liked to do. Differentials?

Answer 7

Insomnia related to major depressive disorder
Primary hypersomnia
Insomnia with circadian rhythm sleep disorder

Question 8

33 yo F complains of three weeks of fatigue and trouble falling asleep easily but wakes up at 3 am and cannot return to sleep. She also reports an unintentional weight loss of 3.5 kg along with an inability to enjoy the things she once liked to do. Differentials: insomnia related to major depressive disorder, primary hypersomnia, insomnia with circadian rhythm sleep disorder. Workup?

Answer 8

Mental status exam
TSH
CBC