Pharmacological management of sleep disorders — MCQs

An otherwise healthy 55-year-old woman comes to the physician because of a 7-month history of insomnia. She has difficulty initiating sleep, and her sleep onset latency is normally about 1 hour. She takes melatonin most nights. The physician gives the following recommendations: leave the bedroom when unable to fall asleep within 20 minutes to read or listen to music; return only when sleepy; avoid daytime napping. These recommendations are best classified as which of the following?

A 17-year-old man presents to his primary care physician concerned about excessive sleepiness that has persisted his entire life. He notes that he has been having difficulty with his job as a waiter because he often falls asleep suddenly during the day. He also experiences a sensation of dreaming as he goes to sleep even though he still feels awake. He sleeps about 10 hours per day and still feels tired throughout the day. The patient has even reported driving into a tree once as he fell asleep while driving. The patient often stays up late at night working on the computer. Physical exam demonstrates an obese young man who appears tired. His oropharynx demonstrates high palatal ridges and good dental hygiene. Which of the following is the best next step in management?

A 19-year-old man is seen by his primary care physician. The patient has a history of excessive daytime sleepiness going back several years. He has begun experiencing episodes in which his knees become weak and he drops to the floor when he laughs. He has a history of marijuana use. His family history is notable for hypertension and cardiac disease. His primary care physician refers him for a sleep study, which confirms your suspected diagnosis. Which of the following is the best first-line pharmacological treatment for this patient?

A 53-year-old woman presented to her PCP with one week of difficulty falling asleep, despite having good sleep hygiene. She denies changes in her mood, weight loss, and anhedonia. She has had difficulty concentrating and feels tired throughout the day. Recently, she was fired from her previous job. What medication would be most helpful for this patient?

A 31-year-old man presents to his primary care physician endorsing three months of decreased sleep. He reports an inability to fall asleep; although once asleep, he generally sleeps through the night and wakes up at a desired time. He has instituted sleep hygiene measures, but this has not helped. He has not felt anxious or depressed and is otherwise healthy. You prescribe him a medication that has the potential side effect of priapism. From which of the following locations is the neurotransmitter affected by this medication released?

A 62-year-old man presents to his geriatrician due to waking several times during the night and also rising too early in the morning. He says this has worsened over the past 7 months. In the morning, he feels unrefreshed and tired. His medical history is positive for hypertension and benign prostatic hyperplasia. He has never been a smoker. He denies drinking alcohol or caffeine prior to bedtime. Vital signs reveal a temperature of 36.6°C (97.8°F), blood pressure of 130/80 mm Hg, and heart rate of 77/min. Physical examination is unremarkable. After discussing good sleep hygiene with the patient, which of the following is the best next step in the management of this patient’s condition?

A 32-year-old man comes to the physician because of generalized fatigue for the past 4 months. He also has difficulty sleeping and concentrating. He says he does not enjoy his hobbies anymore and has stopped attending family events. Mental status examination shows psychomotor retardation and a flat affect along with some evidence of suicidal ideation. His speech is slow in rate and monotone in rhythm. Treatment with fluoxetine is initiated. One month later, he reports significant improvement in his motivation and mood but also delayed ejaculation and occasional anorgasmia. The physician decides to replace his current medication with another agent. It is most appropriate to switch the patient to which of the following drugs?

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 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 21-year-old man presents to the clinic complaining of feeling tired during the day. He is concerned as his grades in school have worsened and he does not want to lose his scholarship. Upon further questioning, the patient describes frequently experiencing a dreamlike state before falling asleep and after waking up. He also has frequent nighttime awakenings where he finds himself unable to move. He denies snoring. The patient does not drink alcohol or abuse any other drugs. The patient's BMI is 21 kg/m2, and his vital signs are all within normal limits. What is this patient's diagnosis?