Difficulty Sleeping Mnemonic (Insomnia):
Having trouble remembering all the important questions to ask during your patient encounter? Then try this Insomnia (Sleeping Problem) Mnemonic for USMLE Step 2 CS.
Physical Examination Difficulty Sleeping Mnemonic
NOTE: Make sure to wash your hands or wear gloves before you start physical examination. Make sure to ask for permission before you start each physical exam. Make sure to use proper draping (don’t forget to tie back patient’s gown). Make sure to explain each physical examination in layman’s term to your patient. Do NOT repeat painful maneuvers.
- HEENT exam: Thyroid, Lymphadenopathy
- Cardiovascular exam: Auscultation
- Pulmonary exam: Auscultation
- Abdominal exam: Auscultation
- Extremities: Check for tremor on outstretched fingertips & edema
- Skin: Inspection for dryness
- Neurologic: DTRs, Brisk reflexes
Differential Diagnosis Difficulty Sleeping Mnemonic
- Anxiety: Sleep disturbances are common in anxiety states. The clinical manifestations of anxiety can be both psychological (eg, tension, fears, difficulty concentrating) and somatic (eg, tachycardia, sweating, hyperventilation, palpitations, tremor).
- Caffeine-induced insomnia
- Hyperthyroidism: Clinical hyperthyroidism is associated with anxiety, tremor, palpitations, sweating, frequent bowel movements, fatigue, menstrual irregularities, unintentional weight loss, and heat intolerance.
- Insomnia related to depression: Depression can be associated with sleep onset insomnia, sleep maintenance insomnia, or early-morning wakefulness. Hypersomnia occurs in some depressed patients, especially adolescents and those with either bipolar or seasonal (fall/winter) depression.
- Advanced Sleep phase disorder: is a condition in which patients feel very sleepy and go to bed early in the evening (e.g. 6:00–8:00 p.m.) and wake up very early in the morning (e.g. around 3:00 a.m.).
- Delayed sleep phase syndrome: is a disorder in which a person’s sleep is delayed by 2 or more hours beyond the socially acceptable or conventional bedtime. This delay in falling asleep causes difficulty in waking up at the desired time.
- Adjustment insomnia: Any significant life event, such as a change of occupation, loss of a loved one, illness, or examinations, can be a significant stressful event in people’s lives.
- Illicit drug abuse: Drugs such as cocaine and amphetamine increase sympathetic activity and can thus cause insomnia.
- Obstructive sleep apnea: More than 50% of patients evaluated for OSA complain of symptoms of insomnia, including difficulty in initiating and maintaining sleep and early-morning awakening.
Diagnostic Work up Difficulty Sleeping Mnemonic
- TSH, Free T4: to rule out underlying thyroid disorder
- Complete Blood Count (CBC): Can help detect anemia, hidden infection, or malignancy, all of which can cause the fatigue and weight loss seen in this patient.
- Urine drug test: to rule out the use of CNS stimulants that can cause insomnia (eg, cocaine, amphetamine).
- Polysomnography: to identify if patient has obstructive sleep apnea
- ECG: to rule out possible arrhythmias and nonspecific changes can be seen with hyperthyroidism and anxiety disorders.
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