-Year-Old Woman Says She Has Been Missing Days

A 52-year-old woman complains that she has been missing days of work almost every week

A 52-year-old woman complains that she has been missing days of work almost every week. She states she is neglecting her family, and she is sleeping during the day but cannot sleep at night. She denies other health problems, medication, or environmental allergies. Discussion Prompt #1 What are some clinical assessment tools or techniques that you could use to help diagnose this patient’s condition? From the information provided, list your differential diagnoses in the order of “most likely†to “possible but unlikely.

Paper For Above instruction

The clinical presentation of a 52-year-old woman experiencing frequent absence from work, daytime sleepiness, and insomnia suggests a complex underlying condition that warrants a thorough assessment. The primary challenge here lies in differentiating between potential sleep disorders, psychiatric conditions, and other medical issues that could account for her symptoms. In this context, appropriate clinical assessment tools and techniques are crucial in establishing an accurate diagnosis and guiding effective management.

To begin, a comprehensive patient history is essential. This should include detailed inquiries about sleep patterns, duration, and quality; behavioral factors; stress levels; mood disturbances; substance use; and any recent lifestyle changes. Understanding her sleep-wake cycle, including her tendency to sleep during the day and difficulty sleeping at night, can highlight circadian rhythm disruptions or other sleep-related abnormalities. A sleep diary maintained over at least one to two weeks can provide valuable insights into her sleep patterns, duration, and any nocturnal awakenings.

Subjective assessments can be augmented with validated questionnaires such as the Epworth Sleepiness Scale (ESS) to quantify daytime sleepiness, and the Pittsburgh Sleep Quality Index (PSQI) to evaluate sleep quality. These tools help in objectively assessing the severity of her sleep disturbances and can be useful in monitoring treatment response.

Further, screening for psychiatric conditions, especially depression and anxiety, should be performed using standardized instruments like the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder 7-item scale (GAD-7). Such conditions often co-occur with sleep disorders and can exacerbate symptoms like insomnia and fatigue, thus influencing her work absenteeism. Given her neglect of family and social withdrawal, these assessments are particularly relevant.

Physical examination might uncover signs of other medical issues such as hypothyroidism, which can cause fatigue and sleep disturbances. Laboratory tests including thyroid function tests, complete blood count (CBC), metabolic panel, and screening for substance use may help identify underlying medical causes.

When initial assessments point toward a sleep disorder, objective sleep studies become essential. Polysomnography (PSG) is the gold standard for diagnosing conditions like obstructive sleep apnea (OSA), periodic limb movement disorder, or other sleep-disordered breathing conditions. Given her daytime sleepiness and disturbed nocturnal sleep, OSA is a significant differential diagnosis. Evaluating her with a sleep study can confirm or rule out such conditions.

Actigraphy, a non-invasive method of monitoring rest/activity cycles over extended periods, can also be useful. It helps in assessing circadian rhythm disorders and monitoring the effectiveness of interventions aimed at restoring normal sleep patterns.

Differential Diagnoses (Most Likely to Possible but Unlikely)

  1. Insomnia Disorder (primary sleep disorder characterized by difficulty initiating or maintaining sleep)
  2. Obstructive Sleep Apnea (OSA)
  3. Major depressive disorder with insomnia
  4. Delayed Sleep Phase Syndrome (a circadian rhythm sleep-wake disorder)
  5. Hypothyroidism
  6. Chronic Fatigue Syndrome
  7. Substance use or medication effects (e.g., sedatives, stimulants)
  8. Anxiety disorder or other psychiatric conditions
  9. Sleep-related movement disorders (e.g., restless legs syndrome)
  10. Environmental or occupational factors affecting sleep hygiene

In summary, a combination of detailed patient history, validated questionnaires, physical examination, laboratory tests, and diagnostic sleep studies form the cornerstone of assessment. Recognizing the most probable conditions—such as primary insomnia, sleep apnea, and depression—can facilitate prompt intervention and improve her functional status.

References

  • American Academy of Sleep Medicine. (2014). The International Classification of Sleep Disorders, 3rd Edition. American Academy of Sleep Medicine.
  • Buysse, D. J. (2014). Clinical Practice: Sleep Disorders. New England Journal of Medicine, 370(17), 1530–1540.
  • Johns, M. W. (1991). A New Method for Measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep, 14(6), 540–545.
  • Rechtschaffen, A., & Kales, A. (1968). A Manual of Standardized Terminology, Technique, and Scoring System for Sleep Stages of Human Subjects. U.S. Department of Health, Education, and Welfare.
  • Morin, C. M., & Benca, R. (2012). Chronic Insomnia. The Lancet, 379(9821), 1129–1141.
  • National Institutes of Health. (2011). Sleep Disorders. https://www.nih.gov/
  • Kaplan, H. I., & Sadock, B. J. (2015). Kaplan & Sadock’s Synopsis of Psychiatry. Wolters Kluwer.
  • Chung, F., et al. (2016). STOP-Bang Questionnaire: A Practical Approach to Screen for Obstructive Sleep Apnea. Anesthesiology, 124(5), 978–987.
  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
  • Young, T., et al. (1993). The Occurrence of Sleep-Disordered Breathing among Middle-Aged Adults. New England Journal of Medicine, 328(17), 1230–1235.

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