ABIM & Internal Medicine Shelf Exam Review Question of the Week: 67-year-old male with Excessive Daytime Sleepiness
As we begin #NeuroWeek in our preparation of the ABIM and Internal Medicine Shelf exam review, here is a question directly out of the Knowmedge QVault. Give it your best shot and then see below for the answer.
67-year-old male presents with excessive daytime sleepiness. He admits to sleeping well at night but having moments at different times of the day when he suddenly falls asleep. While at work, he takes naps at the desk for extended periods of time. He says that once he went to fill gas in his car and did not even get out of the car to pump gas when he had a “sleep attack” lasting a couple of hours. He denies snoring at night or experiencing early morning headaches. He states that his extremities become weak when he gets excited. He also has hallucinations upon sleeping and also says upon awakening, he has a sense of not being able to move because it feels like his arms or legs “go to sleep” and are numb. He has tried and failed sleep hygiene. Based on what this patient has, what is the best next step in management?
A. Zolpidem B. CPAP machine C. Modafinil D. Eszopiclone E. Increased caffeine intake
ABIM Exam Practice Question Explanation
This patient likely has narcolepsy, a condition in which individuals have excessive daytime sleepiness despite getting adequate sleep throughout the night. They usually take naps throughout the day and sometimes at odd places or times. Other symptoms associated with narcolepsy are cataplexy (weakness or flaccid muscles upon excitement), hypnagogic hallucinations, and sleep paralysis upon awakening. The mainstay of treatment for this condition is Choice C (Modafinil), a non-amphetamine drug. Sometimes amphetamine-containing drugs are required for treatment as well. Patients who have cataplexy can be treated with tricyclic anti-depressants like desipramine or imipramine.
Let’s go over the answer choices:
● Choice A (Zolpidem) and Choice D (Eszopiclone) can be used for patients who have chronic insomnia. He is not experiencing insomnia as he reports good sleep at night.
● Choice B (CPAP machine) is also not recommended as this patient’s history does not support a diagnosis of obstructive sleep apnea. He denies snoring at night or headaches in the morning. Furthermore, he has the classic symptoms of narcolepsy, including sudden “sleep attacks.”
● Choice E (Increased caffeine intake) is not the correct answer. Caffeine may help him have less daytime sleepiness but there is an underlying diagnosis here that is unrelated to inadequate caffeine intake and needs to be addressed.
You can view all the previous ABIM Exam Review Questions of the Week at the Knowmedge Blog. You can also find additional topics and questions directly from the Knowmedge Internal Medicine ABIM Board Exam Review Questions QVault.