Tuesday, 20 November 2012

Usmle Step 1 MCQ's # 22

Title: Usmle Step 1 MCQ's # 22
Subject: Behavioral Science

Q NO 22: A 45-year-old man has been having problems staying asleep for the past year. He typically goes to bed alter watching the news at 11:30 PM and has no trouble tailing asleep, however, he keeps awakening and always feels tired all day while at work. His primary physician refers him to the university’ sleep center where an overnight polysomnogram is performed. During the study, he is found to have decreased stage 1 sleep, and decreased delta and REM sleep. He has frequent awakenings associated with gasping breaths, oxygen desaturations (monitored by pulse oximetry), and bradycardia. The best initial medical therapy for this problem would be which of the following?

A. Behavioral therapy
B. Imipramine
C. Tonsillectomy and adenoidectomy
D. Triazolam
E. Weight loss and use of continuous positive airway pressure (CPAP)

Explanation:
The correct answer is E. This is a classic description of a person with obstructive sleep apnea (OSA) syndrome. The patient is typically a middle-age, obese male who snores loudly during sleep. The problem stems from obstruction from tissues of the nasopharynx and hypopharynx. The obstruction results in significant periods of apnea associated with arterial hypoxemia and bradycardia. The patient may develop both system and pulmonary hypertension and is at a high risk of sudden death during sleep due to severe hypoxemia and arrhythmias. Often the patient will have a long apneic period followed by gasping respirations and awakening. This cycle repeats over the course of the night and therefore, the patient actually gets little sleep resulting in daytime somnolence. On a polysomnogram (multichannel recording of sleep), one sees a decrease in stage 1 sleep. This is the first stage on non-REM (NREM) sleep. Most adults spend most of the sleep cycle in stage 2 NREM sleep. Stage 3 and 4 NREM sleep is deep sleep and together constitutes delta sleep. The time in REM sleep gets longer as the night progresses and therefore occurs mostly during the last halt of the night. In OSAI we also see a decrease in delta sleep and REM sleep is also decreased. The initial medical treatment for OSA is weight loss with a trial of nasal prong or face mask continuous positive airway pressure (CPAP). Many are noncompliant with this therapy because the presence of the CPAP is felt to be uncomfortable and prevents the patient from falling asleep. Ultimately, one of several surgical procedures involving the removal of tissue from the naso- and hypopharynx may be performed.

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