Sleep disorders related to medical conditions US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Sleep disorders related to medical conditions. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Sleep disorders related to medical conditions US Medical PG Question 1: A 54-year-old man comes to the physician because of excessive daytime sleepiness for 5 months. He wakes up frequently at night, and his wife says his snoring has become louder. He is 180 cm (5 ft 10 in) tall and weighs 104 kg (230 lb); his BMI is 33 kg/m2. His pulse is 80/min and his respiratory rate is 11/min. His jugular venous pressure is 7 cm H2O. He has 2+ pitting edema of the lower legs and ankles. Arterial blood gas analysis on room air shows a pH of 7.42 and a PCO2 of 41 mm Hg. An x-ray of the chest shows normal findings. Which of the following is the most likely underlying cause of this patient's condition?
- A. Daytime alveolar hypoventilation
- B. Decreased levels of hypocretin-1
- C. Increased medullary ventilatory responsiveness
- D. Impaired myocardial relaxation
- E. Intermittent collapse of the oropharynx (Correct Answer)
Sleep disorders related to medical conditions Explanation: ***Intermittent collapse of the oropharynx***
- The patient's symptoms of **excessive daytime sleepiness**, frequent night awakenings, and **loud snoring** are classic signs of **obstructive sleep apnea (OSA)**.
- OSA is characterized by the **intermittent collapse of the oropharynx** during sleep, leading to obstructed airflow. His obesity (BMI 33 kg/m2) is a significant risk factor for OSA.
*Daytime alveolar hypoventilation*
- This would typically present with **elevated PCO2** on arterial blood gas, indicating CO2 retention. The patient's PCO2 of 41 mm Hg is within the normal range, ruling out significant daytime alveolar hypoventilation.
- While chronic severe OSA can eventually lead to obesity hypoventilation syndrome, the current ABG does not support this as the primary underlying cause.
*Decreased levels of hypocretin-1*
- **Decreased hypocretin-1** (also known as orexin) levels in the cerebrospinal fluid are a hallmark of **narcolepsy type 1**.
- While narcolepsy causes excessive daytime sleepiness, it is not associated with loud snoring or night awakenings due to respiratory effort, which are prominent in this patient.
*Increased medullary ventilatory responsiveness*
- **Increased medullary ventilatory responsiveness** would lead to an enhanced drive to breathe, often resulting in **hypocapnia (low PCO2)**, especially in response to metabolic acidosis or hypoxemia.
- This is contrary to the patient's normal PCO2 and clinical picture, which points towards an obstructive rather than a central ventilatory issue.
*Impaired myocardial relaxation*
- **Impaired myocardial relaxation** is a feature of **diastolic heart failure**, which could explain the elevated JVP and peripheral edema.
- However, it does not explain the primary presenting symptoms of excessive daytime sleepiness and loud snoring, which point directly to a sleep-related breathing disorder rather than primarily a cardiac issue.
Sleep disorders related to medical conditions US Medical PG Question 2: A 39-year-old woman comes to the physician for difficulty sleeping and poor concentration at work. She sleeps with the lights turned on and wakes up frequently during the night with palpitations and profuse sweating. Three weeks ago she was sexually assaulted in her car. Since the assault she has avoided using her car and only uses public transportation. She also has nightmares of her attacker. She has been sent home from work for yelling at her coworkers. She has Hashimoto thyroiditis. Current medications include levothyroxine. She has been treated for pelvic inflammatory disease in the past. She has tried alcohol and melatonin to help her sleep. Mental status examination shows a depressed mood and a negative affect. Which of the following is the most likely diagnosis?
- A. Post-traumatic stress disorder
- B. Persistent complex bereavement disorder
- C. Acute stress disorder (Correct Answer)
- D. Adjustment disorder
- E. Adverse effect of medication
Sleep disorders related to medical conditions Explanation: ***Acute stress disorder***
- The patient experiences **intrusive memories** (nightmares), **avoidance** (of her car), **negative mood** (depressed mood, negative affect), **dissociative symptoms** (difficulty concentrating, feeling dazed), and **arousal symptoms** (difficulty sleeping, palpitations, profuse sweating, irritability) within **one month of a traumatic event** (sexual assault).
- These symptoms cause **significant distress** and **functional impairment**, meeting the diagnostic criteria for acute stress disorder.
*Post-traumatic stress disorder*
- This diagnosis is considered if the symptoms persist for **longer than one month** after the traumatic event.
- While the patient exhibits many PTSD symptoms, the **timeline** (three weeks since the assault) fits acute stress disorder more precisely.
*Persistent complex bereavement disorder*
- This disorder is diagnosed in response to the **death of a loved one** where grief symptoms are unusually prolonged and impairing.
- The patient's symptoms are a direct result of a **sexual assault**, not the death of a loved one.
*Adjustment disorder*
- Adjustment disorder involves emotional or behavioral symptoms in response to an **identifiable stressor**, but the symptoms are **less severe** and do not meet the full criteria for other specific mental disorders.
- The patient's symptoms are extensive, debilitating, and clearly meet criteria for a more specific stress-related disorder.
*Adverse effect of medication*
- While some medications can cause sleep disturbances or mood changes, the patient's symptoms are directly tied to a **recent traumatic event** and include classic features of a stress-related disorder.
- Her current medication, **levothyroxine**, is unlikely to cause a sudden onset of such a complex constellation of symptoms, especially avoidance behaviors and flashbacks.
Sleep disorders related to medical conditions US Medical PG Question 3: A 47-year-old man presents with a history of a frequent unpleasant crawling sensation in both of his legs accompanied by an urge to move his legs for the last 6 months. He continuously moves his legs to provide him with partial relief from the unpleasant feelings in his legs. The symptoms are especially severe during the night or while lying down in bed after returning from work. These symptoms occur 3–5 days per week. He also complains of significant daytime fatigue and sleep disturbances on most days of the week. He is advised to take a polysomnography test, which reveals periodic limb movements (PLMs) during his sleep. Which of the following conditions is most associated with secondary restless legs syndrome?
- A. Pulmonary tuberculosis
- B. Vitamin B3 deficiency
- C. Zinc deficiency
- D. Liver failure
- E. Iron deficiency anemia (Correct Answer)
Sleep disorders related to medical conditions Explanation: ***Iron deficiency anemia***
- **Iron deficiency** is a common cause of **secondary Restless Legs Syndrome (RLS)**, as iron is crucial for dopamine synthesis in the brain, which is implicated in RLS pathophysiology.
- Evaluation of RLS often includes testing **serum ferritin levels** to assess iron stores.
*Pulmonary tuberculosis*
- While tuberculosis can cause systemic symptoms and chronic illness, it is **not directly associated** with the pathophysiology of RLS.
- The focus of tuberculosis is on the respiratory system and other organs where the infection manifests.
*Vitamin B3 deficiency*
- **Vitamin B3 deficiency**, or **pellagra**, primarily affects the skin, gastrointestinal tract, and nervous system, causing dermatitis, diarrhea, and dementia.
- It does **not typically present** with or directly cause RLS symptoms.
*Zinc deficiency*
- **Zinc deficiency** can lead to various symptoms like immune dysfunction, hair loss, and skin lesions.
- There is **no established direct link** between zinc deficiency and the development of RLS.
*Liver failure*
- **Liver failure** can cause a range of neurological symptoms such as **encephalopathy** and peripheral neuropathy.
- However, it is **not a primary or common cause** of secondary RLS.
Sleep disorders related to medical conditions US Medical PG Question 4: A 16-year-old girl is brought to the physician because of generalized fatigue and an inability to concentrate in school for the past 4 months. During this period, she has had excessive daytime sleepiness. While going to sleep, she sees cartoon characters playing in her room. She wakes up once or twice every night. While awakening, she feels stiff and cannot move for a couple of minutes. She goes to sleep by 9 pm every night and wakes up at 7 am. She takes two to three 15-minute naps during the day and wakes up feeling refreshed. During the past week while listening to a friend tell a joke, she had an episode in which her head tilted and jaw dropped for a few seconds; it resolved spontaneously. Her father has schizoaffective disorder and her parents are divorced. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate initial pharmacotherapy?
- A. Modafinil (Correct Answer)
- B. Venlafaxine
- C. Risperidone
- D. Oral contraceptive pill
- E. Citalopram
Sleep disorders related to medical conditions Explanation: ***Modafinil***
- This patient's symptoms (excessive daytime sleepiness, hypnagogic hallucinations, sleep paralysis, cataplexy, and refreshing naps) are highly suggestive of **narcolepsy**.
- **Modafinil** is a wake-promoting agent and is a first-line treatment for excessive daytime sleepiness in narcolepsy.
*Venlafaxine*
- **Venlafaxine** is a serotonin-norepinephrine reuptake inhibitor (SNRI) that can be used to treat cataplexy in narcolepsy by suppressing REM sleep.
- While cataplexy is present, the primary and most debilitating symptom is excessive daytime sleepiness, for which modafinil is the initial choice.
*Risperidone*
- **Risperidone** is an antipsychotic medication, primarily used to treat schizophrenia and bipolar disorder.
- Although the patient experiences hypnagogic hallucinations, these are part of narcolepsy symptoms and not indicative of a primary psychotic disorder warranting antipsychotic treatment.
*Oral contraceptive pill*
- An **oral contraceptive pill** is used for contraception or managing hormonal-related conditions such as irregular menstruation, acne, or polycystic ovary syndrome.
- There is no indication in the patient's presentation that would warrant treatment with oral contraceptives.
*Citalopram*
- **Citalopram** is a selective serotonin reuptake inhibitor (SSRI) and is typically used to treat depression or anxiety disorders.
- While sometimes used off-label for cataplexy in narcolepsy due to its REM-suppressing effects, it is not the initial treatment for the primary symptom of excessive daytime sleepiness.
Sleep disorders related to medical conditions US Medical PG Question 5: A 65-year-old male with multiple comorbidities presents to your office complaining of difficulty falling asleep. Specifically, he says he has been having trouble breathing while lying flat very shortly after going to bed. He notes it only gets better when he adds several pillows, but that sitting up straight is an uncomfortable position for him in which to fall asleep. What is the most likely etiology of this man's sleeping troubles?
- A. Left-sided heart failure (Correct Answer)
- B. Amyotrophic lateral sclerosis (ALS)
- C. Obstructive sleep apnea
- D. Right-sided heart failure
- E. Myasthenia gravis
Sleep disorders related to medical conditions Explanation: ***Left-sided heart failure***
- The patient's inability to breathe while lying flat (orthopnea) and the relief obtained by elevating his head with pillows is a classic symptom of **left-sided heart failure**.
- In this condition, accumulation of fluid in the lungs (pulmonary congestion) due to the heart's inability to pump blood effectively leads to difficulty breathing, especially in the recumbent position.
*Amyotrophic lateral sclerosis (ALS)*
- ALS primarily affects **motor neurons**, leading to progressive muscle weakness, atrophy, and spasticity.
- While it can eventually cause respiratory muscle weakness, it typically presents with more generalized motor symptoms and does not specifically manifest as acute orthopnea relieved by elevating the head of the bed shortly after lying down.
*Obstructive sleep apnea*
- Obstructive sleep apnea is characterized by recurrent upper airway collapse during sleep, leading to **pauses in breathing** and loud snoring.
- While it can cause fragmented sleep and daytime sleepiness, the primary relief is not typically from simply adding pillows but rather from CPAP therapy or surgical interventions to open the airway.
*Right-sided heart failure*
- Right-sided heart failure primarily leads to **systemic venous congestion**, causing symptoms like peripheral edema, ascites, and jugular venous distension.
- It does not typically cause orthopnea as a primary symptom, as pulmonary congestion is not the predominant feature.
*Myasthenia gravis*
- Myasthenia gravis is an **autoimmune disorder** characterized by fluctuating weakness of voluntary muscles, which worsens with activity and improves with rest.
- While it can affect respiratory muscles in severe cases, leading to respiratory compromise, the symptom presentation is more varied than isolated orthopnea, and it does not typically manifest acutely only when lying flat to sleep.
Sleep disorders related to medical conditions US Medical PG Question 6: A 15-year-old boy is brought to the physician with excessive daytime sleepiness over the past year. His parents are concerned with his below-average school performance over the last 3 months. He goes to bed around midnight and wakes up at 7 am on school days, but sleeps in late on weekends. He exercises regularly after school. He usually has a light snack an hour before bed. He does not snore or have awakenings during sleep. He has no history of a serious illness and takes no medications. The boy was born at 39 weeks gestation via spontaneous vaginal delivery. He is up to date on all vaccines and is meeting all developmental milestones. He does not smoke or drink alcohol. There is no history of a similar problem in the family. His vital signs are within normal limits. His BMI is 22 kg/m2. Physical examination shows no abnormal findings. Which of the following is the most appropriate recommendation at this time?
- A. Take melatonin before bedtime
- B. Avoid snacks before bedtime
- C. Decrease exercise intensity
- D. Increase nighttime sleep hours (Correct Answer)
- E. Take a nap in the afternoon
Sleep disorders related to medical conditions Explanation: ***Increase nighttime sleep hours***
- The patient's pattern of going to bed at midnight and waking at 7 AM on school days, along with sleeping in late on weekends, suggests a **chronic sleep deficit** accumulated during the week. Adolescents typically require 8-10 hours of sleep per night.
- The excessive daytime sleepiness and declining school performance are strong indicators of insufficient sleep, and **prioritizing more sleep during school nights** is the most direct intervention.
*Take melatonin before bedtime*
- Melatonin supplements are typically used for **sleep-onset insomnia** or **circadian rhythm disorders**, neither of which is clearly indicated here.
- There is no evidence presented of difficulty falling asleep; rather, the issue appears to be insufficient duration of sleep due to **late bedtime schedules**.
*Avoid snacks before bedtime*
- While heavy meals before bedtime can disrupt sleep, this patient reports having only a **light snack**, which is unlikely to be the primary cause of his significant daytime sleepiness.
- There is no mention of indigestion or gastrointestinal discomfort after the snack that would point to this as a problem.
*Decrease exercise intensity*
- Regular exercise generally **improves sleep quality**, and there's no indication that the patient's exercise routine is negatively impacting his sleep.
- While very intense exercise too close to bedtime can be disruptive for some, exercise itself is generally beneficial for sleep and overall health; therefore, reducing it would not be a primary recommendation.
*Take a nap in the afternoon*
- While naps can temporarily alleviate daytime sleepiness, they can also **disrupt nighttime sleep patterns** by reducing sleep drive.
- Napping would be treating the symptom rather than the root cause, which is a **chronic lack of sufficient nighttime sleep**.
Sleep disorders related to medical conditions US Medical PG Question 7: A 72-year-old man presents to his primary care physician complaining of increasing difficulty sleeping over the last 3 months. He reports waking up frequently during the night because he feels an urge to move his legs, and he has a similar feeling when watching television before bed. The urge is relieved by walking around or rubbing his legs. The patient’s wife also notes that she sometimes sees him moving his legs in his sleep and is sometimes awoken by him. Due to his recent sleep troubles, the patient has started to drink more coffee throughout the day to stay awake and reports having up to 3 cups daily. The patient has a past medical history of hypertension and obesity but states that he has lost 10 pounds in the last 3 months without changing his lifestyle. He is currently on hydrochlorothiazide and a multivitamin. His last colonoscopy was when he turned 50, and he has a family history of type II diabetes and dementia. At this visit, his temperature is 99.1°F (37.3°C), blood pressure is 134/81 mmHg, pulse is 82/min, and respirations are 14/min. On exam, his sclerae are slightly pale. Cardiovascular and pulmonary exams are normal, and his abdomen is soft and nontender. Neurologic exam reveals 2+ reflexes in the bilateral patellae and 5/5 strength in all extremities. Which of the following is most likely to identify the underlying etiology of this patient's symptoms?
- A. Colonoscopy (Correct Answer)
- B. Trial of iron supplementation
- C. Trial of reduction in caffeine intake
- D. Trial of pramipexole
- E. Dopamine uptake scan of the brain
Sleep disorders related to medical conditions Explanation: ***Colonoscopy***
- The patient presents with **classic restless legs syndrome (RLS)** symptoms along with multiple red flags: **unexplained 10-pound weight loss**, **pale sclerae** suggesting anemia, and a **remote last colonoscopy 22 years ago**.
- These findings raise significant concern for **gastrointestinal malignancy** (particularly colon cancer) causing chronic occult blood loss, leading to **iron deficiency anemia**, which is a well-known secondary cause of RLS.
- **Colonoscopy is the definitive diagnostic test** that would identify the underlying etiology (e.g., colon cancer, other GI bleeding source) causing the iron deficiency and subsequent RLS symptoms.
- At age 72 with the last colonoscopy at age 50, the patient is significantly overdue for colorectal cancer screening, making this investigation both urgent and appropriate.
*Trial of iron supplementation*
- While iron deficiency is likely contributing to the RLS symptoms, a **therapeutic trial does not identify the underlying etiology** - it only treats the consequence.
- Given the concerning red flags (weight loss, anemia, overdue screening), it would be premature to simply supplement iron without investigating the **source of iron loss**, which could be a malignancy.
- Iron supplementation may temporarily improve RLS but would delay diagnosis of a potentially serious underlying condition.
*Trial of reduction in caffeine intake*
- While caffeine can exacerbate RLS symptoms, the patient only increased coffee intake **after** developing sleep problems (as a compensatory mechanism).
- The presence of weight loss and anemia indicates a more serious underlying pathology that would not be addressed by reducing caffeine.
- Caffeine reduction alone would not identify any underlying etiology.
*Trial of pramipexole*
- Pramipexole is a **dopamine agonist** used for symptomatic treatment of RLS.
- However, it is important to **identify and treat secondary causes** (like iron deficiency from GI blood loss) before initiating dopaminergic therapy.
- This would be premature without first investigating the red flag symptoms suggesting serious underlying pathology.
*Dopamine uptake scan of the brain*
- A **DAT scan** is used to differentiate Parkinson's disease from essential tremor or other movement disorders, which is not relevant here.
- RLS is a **clinical diagnosis** based on symptoms, and dopamine imaging is not indicated for RLS diagnosis or workup.
- This test would not identify the underlying etiology of this patient's symptoms.
Sleep disorders related to medical conditions US Medical PG Question 8: A 5-year-old boy is brought to the physician by his parents because of 2 episodes of screaming in the night over the past week. The parents report that their son woke up suddenly screaming, crying, and aggressively kicking his legs around both times. The episodes lasted several minutes and were accompanied by sweating and fast breathing. The parents state that they were unable to stop the episodes and that their son simply went back to sleep when the episodes were over. The patient cannot recall any details of these incidents. He has a history of obstructive sleep apnea. He takes no medications. His vital signs are within normal limits. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?
- A. Restless legs syndrome
- B. Nightmare disorder
- C. Sleepwalking disorder
- D. Insomnia disorder
- E. Sleep terror disorder (Correct Answer)
Sleep disorders related to medical conditions Explanation: ***Sleep terror disorder***
- This patient's presentation with sudden nocturnal screaming, agitation, autonomic arousal (sweating, fast breathing), and subsequent **amnesia** for the event is classic for **sleep terror disorder**.
- The inability of parents to awaken or comfort the child, followed by the child returning to sleep and having **no recall**, are key diagnostic features.
*Restless legs syndrome*
- Characterized by an irresistible urge to move the legs, often accompanied by uncomfortable sensations, typically occurring or worsening during periods of **rest** or **inactivity**, and partially or totally relieved by movement.
- This condition does not involve screaming, intense fear, or amnesia for a sleep event.
*Nightmare disorder*
- Nightmares are typically **vivid, frightening dreams** from which the individual awakens fully alert and often recalls the dream in detail.
- Unlike sleep terrors, nightmares occur during **REM sleep** (usually later in the night), and the child is usually consolable after waking.
*Sleepwalking disorder*
- Involves complex motor behaviors, such as walking, while still asleep, without full consciousness.
- While it can occur during NREM sleep and involves partial amnesia, it typically **does not feature screaming, intense fear, or significant autonomic arousal** as the predominant symptom.
*Insomnia disorder*
- Defined by persistent difficulty with **sleep initiation, duration, consolidation, or quality**, despite adequate opportunity for sleep, leading to daytime impairment.
- It does not involve acute episodes of screaming or terror during sleep as described.
Sleep disorders related to medical conditions US Medical PG Question 9: A 17-year-old high school student comes to the physician because of a 6-month history of insomnia. On school nights, he goes to bed around 11 p.m. but has had persistent problems falling asleep and instead studies at his desk until he feels sleepy around 2 a.m. He does not wake up in the middle of the night. He is worried that he does not get enough sleep. He has significant difficulties waking up on weekdays and has repeatedly been late to school. At school, he experiences daytime sleepiness and drinks 1–2 cups of coffee in the mornings. He tries to avoid daytime naps. On the weekends, he goes to bed around 2 a.m. and sleeps in until 10 a.m., after which he feels rested. He has no history of severe illness and does not take medication. Which of the following most likely explains this patient's sleep disorder?
- A. Inadequate sleep hygiene
- B. Irregular sleep-wake disorder
- C. Psychophysiologic insomnia
- D. Delayed sleep-wake disorder (Correct Answer)
- E. Advanced sleep-wake disorder
Sleep disorders related to medical conditions Explanation: ***Delayed sleep-wake disorder***
- This patient exhibits a consistent pattern of **delayed sleep onset** and **delayed wake time**, particularly evident on weekends when he can follow his natural circadian rhythm (going to bed at 2 AM and waking at 10 AM).
- The symptoms, including difficulty falling asleep at conventional times, difficulty waking for school, and daytime sleepiness, are classic for **delayed sleep-wake phase disorder**, where an individual's internal clock is misaligned with societal expectations.
*Inadequate sleep hygiene*
- While aspects like studying in bed are **poor sleep hygiene**, the core issue is not simply bad habits but a fundamental misalignment of his **circadian rhythm** as evidenced by his consistent late sleep onset and wake times when allowed.
- The patient's ability to sleep well and feel rested on weekends when he can follow his natural rhythm suggests that hygiene alone isn't the primary cause.
*Irregular sleep-wake disorder*
- This disorder is characterized by a **lack of a discernible sleep-wake rhythm**, with sleep periods fragmented and scattered throughout the 24-hour day.
- The patient, however, demonstrates a clear, albeit delayed, sleep schedule; he sleeps in one consolidated block and feels rested when allowed to do so.
*Psychophysiologic insomnia*
- This condition involves heightened arousal and **anxiety surrounding sleep**, leading to difficulty falling asleep at night and often improved sleep in novel environments or away from home.
- While he expresses worry about not getting enough sleep, his sleep issues are primarily due to a shifted circadian phase, not just anxiety about sleep itself, and he sleeps restfully when allowed to follow his delayed rhythm.
*Advanced sleep-wake disorder*
- This disorder is characterized by a **habitually early sleep onset** and **early morning awakening**, typically several hours earlier than desired or conventional times.
- The patient, in contrast, consistently struggles to fall asleep until very late hours and desires a later wake time.
Sleep disorders related to medical conditions US Medical PG Question 10: A 5-year-old boy is brought to the emergency department by a neighbor who saw him struck by a car. The man reports that the boy is intellectually disabled, and his parents frequently leave him unattended at home for most of the day. He walks around the neighborhood and sometimes has difficulty finding his way home. Today he was struck by a car that sped off. The man called the boy’s mother by phone, but she said that she was too busy to leave her job and asked the man to take the boy to the emergency department for her. A quick review of the boy's electronic medical record reveals that he has not been seen by a physician in several years and has missed several vaccines. On physical exam, the vital signs are normal. He appears dirty, thin, and small for his age with a large bruise forming on his right hip. Which of the following is the most appropriate term for this type of child abuse?
- A. Psychological abuse
- B. Factitious disorder
- C. Physical abuse
- D. Sexual abuse
- E. Neglect (Correct Answer)
Sleep disorders related to medical conditions Explanation: ***Neglect***
- The parents' failure to provide adequate supervision, medical care (missed vaccines, no physician visits), and basic needs (appears dirty, thin, small for age) for the intellectually disabled child despite being able to do so, constitutes **neglect**.
- Their refusal to come to the ED and leaving him unattended further supports the diagnosis of **neglect**.
*Psychological abuse*
- This involves behaviors that harm a child's **self-worth** or **emotional well-being**, such as constant criticism, threats, or terrorizing.
- While emotional harm may be present due to neglect, the primary and most comprehensive description of the actions is neglect of basic needs and care.
*Factitious disorder*
- This is a mental disorder where an individual fakes or induces illness in themselves or someone else (often a child, known as **Factitious Disorder Imposed on Another**) for attention or sympathy.
- The scenario describes a failure of care rather than a deliberate fabrication or induction of illness.
*Physical abuse*
- This involves causing **physical harm** to a child, such as hitting, burning, or shaking. The large bruise on the hip is a sign of injury, but the *cause* is being struck by a car, not direct parental physical harm.
- While a bruise is present, the overall pattern of parental behavior points to a failure to protect and care rather than direct infliction of injury by the parents on the child.
*Sexual abuse*
- This involves any sexual act or exploitation of a child by an adult.
- There are **no indicators** in the provided scenario to suggest sexual abuse.
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