Sleep disorders related to medical conditions — MCQs

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 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 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 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 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 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 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 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 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?