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Clinical Challenge TEST YOUR KNOWLEDGE: Clinical challenge Clinical challenge Questions for this month’s clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the MCQ of the College Fellowship exam. The quiz is endorsed by the RACGP Quality Assurance and Continuing Professional Development Program and has been allocated 2 CPD points per issue. Answers to this clinical challenge will be published next month. Dr Jenni Parsons SINGLE COMPLETION ITEMS Question 3 Questions 6-10 are based on the article ‘Insomnia – Diagnosis and management’ DIRECTIONS by Ron Grunstein Each of the questions or incomplete Ted, aged 73, usually a reserved man, has statements below is followed by five begun shouting and swearing in his sleep, Question 6 suggested answers or completions. as well as punching and kicking. When Select the most appropriate statement as your answer. this happens his wife wakes him and he Susan, aged 42, presents with long term usually remembers a dream in which he difficulties with getting to sleep, which Questions 1-5 are based on the article was fighting. Which is the most likely have worsened over the past few weeks. ‘Parasomnias - Things that go thump in the diagnosis? She lies awake worrying about work, night’ by Phillip King A. confusional arousal stresses with her teenage sons and the fact B. REM sleep behaviour disorder that she is not sleeping. She doesn’t get to Question 1 C. nightmare sleep until 3 or 4 am in the morning. She Ben, aged six, is brought to see you fol- D. night terror gets up at 7 am most days to go to work. lowing three episodes of waking at night E. epilepsy. Choose the correct statement. with a loud scream, and is sweaty, agitated A. Susan’s insomnia puts her at risk of and inconsolable. He paces around the Question 4 developing depression house and appears afraid and anxious. He The following may be associated with B. the vast majority of patients is difficult to rouse to full consciousness. Ted’s problem: presenting with insomnia have an Next morning he is unaware of what has A. Alzheimer disease underlying mood disorder occurred and has no dream recall. The B. Parkinson disease C. patients like Susan are likely to most likely diagnosis is: C. alcohol withdrawal perform well on psychomotor A. temporal lobe epilepsy D. tricyclic antidepressant withdrawal performance tasks B. night terrors E. all of the above. D. insomnia is always a behavioural or C. REM sleep behaviour disorder psychological health problem D. nightmare Question 5 E. Susan is more likely to fall asleep E. confusional arousals. Treatment of REM sleep behaviour dis- during the day than someone with order is with: normal sleep patterns. Question 2 A. explanation and relaxation techniques Management of Ben’s problem would only include: B. low dose tricyclic antidepressants A. EEG C. low dose clonazepam B. CT scan of the brain D. low dose epilim C. explanation of the disorder E. levadopa. D. referral to a child psychologist E. all of the above. 1 • Reprinted from Australian Family Physician Vol. 31, No. 11, November 2002 Clinical challenge n Question 7 Questions 11-15 are based on the article Question 15 ‘Assessment and management of the patient presenting with snoring’ by Matthew Naughton Susan has used temazepam on occasions Kelvin sees a sleep physician and is diag- in the past. You tell her that temazepam: Question 11 nosed with moderate OSA. He is treated A. increases REM sleep with constant positive airway pressure B. decreases REM sleep Kelvin, aged 51, attends at the behest of (CPAP). He complains of a dry mouth C. remains effective for up to three his partner, who is tired of listening to and rhinitis. Which of the following months of continuous use Kelvin snore every night. Factors sugges- strategies is least likely to be helpful: D. does not impair psychomotor tive of obstructive sleep apnoea (OSA) A. changing the type of mask performance the next day as it is do not include: B. humidification short acting A. loud snoring audible in adjacent room C. using a chin strap E. does not cause rebound insomnia. B. snoring more than three nights per D. nasal steroids week E. nasal ipratropium bromide. Question 8 C. snoring occurring only in the AFP You discuss other pharmacological treat- supine position ments including Zopiclone. Choose the D. daytime sleepiness incorrect statement. Zopiclone: E. hypertension. A. is a benzodiazepine-like hypnotic B. decreases the time taken to get Question 12 to sleep You examine Kelvin. Which of the fol- C. causes greater impairment of daytime lowing signs is not associated with OSA: performance than temazepam A. BMI 31 D. maintains sleep architecture B. neck circumference 42 cm E. causes some rebound insomnia C. abdominal girth 130 cm on withdrawal. D. BP 160/100 E. nasal obstruction. Question 9 You discuss sleep hygiene with Susan. Question 13 Which of the following are helpful You tell Kelvin that he may have obstruc- strategies: tive sleep apnoea and discuss referring A. exercising before bed him to a sleep clinic. He asks about mea- B. a glass of alcohol as a nightcap sures that may help his symptoms. You C. setting aside a ‘worry time’ tell him: D. sleeping longer in the morning to A. weight loss is ineffective once OSA is ensure eight hours sleep established E. reading a book in bed until falling B. to have a glass of alcohol before bed asleep. C. nasal steroid sprays have no place in his treatment Question 10 D. avoid sleep deprivation You discuss behavioral therapies for E. to take temazepam at night to improve insomnia with Susan. Choose the tech- the quality of his sleep. nique likely to be most helpful to Susan initially: Question 14 A. relaxation techniques Kelvin’s partner asks about complications B. sleep restriction therapy of OSA. They include: C. stimulus control therapy A. cardiovascular disease D. cognitive therapy B. increased risk of car or industrial E. none of the above. accidents C. neurocognitive impairment D. all of the above E. none of the above. Reprinted from Australian Family Physician Vol. 31, No. 11, November 2002 • 2.
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