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History of Present Illness

Ms. A, a 42 year old woman, is referred to the sleep disorders center with a chief complaint of chronic, severe insomnia affecting her daytime functioning. She first experienced insomnia 5 years ago when bankruptcy threatened her small business. Although the business recovered a year later, Mrs. A’s insomnia remained almost unchanged over the next 8 years.

Ms. A feels that she is just “hanging on by her fingernails,” that taking care of her business and her boys has taken all of her energy while suffering from insomnia. Her lack of sleep has forced her to give up her social life, including her fly-fishing hobby and gym workouts. She feels depleted and stressed and worries that her ability to cope will soon disappear unless she can improve the quality of her sleep. She has begun to drink 4-5 strong mugs of coffee per day to keep awake and tries to catch a nap whenever possible.

She has taken temazepam (Restoril), zolpidem (Ambien), and zaleplon (Sonata) for sleep, and trazodone (Desyrel), amitriptyline (Elavil), and mirtazapine (Remeron, Soltab) for mood. She discontinued sleep medications after 1-2 weeks because of side effects or because they seemed ineffective. She is still on mirtazapine, which has sleep-promoting effects. However it does not seem to help her get back to sleep when she wakes during the night. Also, she takes extra doses of levothyroxine medication occasionally to increase her energy level.

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Past Medical History

• Hypothyriodism X 5 years
• Hemorroids X 7 years

Social History

• Single mother of 3 teenage boys
• Own a small business
• Denies cigarette smoke or drug use
• Drink alcohol occasionally

Medications

• Levothyroxine
• Vitamin D
• Valerian
• Chamomile tea
• Melatonin

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Review of Sleep Pattern

Ms. A sleeps alone although the family dog occasionally sleeps with her. She tries to go to bed after her oldest boy is home and settled—typically around 11:00 PM. She usually falls asleep in less than 15 minutes, but occasionally it takes her “hours.” She awakens 3-4 times per night, and at least 1 of these awakenings lasts 2-3 hours. Ms. A becomes frustrated when she sees “the clock ticking away” and usually gets out of bed to work on the computer until she becomes sleepy, often around 5:30 AM, when it would be time to get up. Then she falls into a very deep sleep and does not awaken until 7:00 AM or 8:00 AM.

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Physical Examination

General Appearance

• Patient is well developed, well nourished, and pleasant
• Appears tired but no apparent distress
• Speech is paced and content us normal

Vital Signs

BP (sitting)            143/83	RR                        16 and unlabored	HT                         5’7”
p                            82 and regular	T                            98.4	WT                        158 lbs
		BMI                        24.7

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Skin

• Normal skin turgor and color
• Warm, moist, and soft
• (-) rashes, bruises or other lesions

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Head, Eyes, Ears, Nose, and Throat

• PERRLA
• EOMs intact
• Eyes anicteric
• Normal conjunctiva
• Vision satisfactory with no eye pain
• Fundi without AV nicking, hemorrhages, exudates, and papilledema
• TMs intact
• (-) tinnitus and ear pain
• Nares clear
• Oropharynx clear with no mouth lesions
• Tongue normal size
• No throat pain or difficulty swallowing

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Neck/Lymph Nodes

• Neck supple
• Trachea mid-line
• No palpable nodes or JVD notes
• No diffused enlargement or tenderness of thyroid

Chest and Lungs

• Chest clear to auscultation
• Normal breath sounds
• (-) axillary and supraclavicular lymphadenopathy

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Heart

• Regular rate and rhythm
• Normal S₁ and S₂
• No rubs or murmurs

Abdomen

• (-) hepatosplenomegaly, fluid wave, tenderness, and distension
• (-) masses, bruits, and superficial abdominal veins
• Normal BS

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Genitalia and Rectum

• No internal rectal masses palpated
• External hemorrhoids noted

Musculoskeletal and Extremities

• (-) spine and costovertebral angle tenderness
• Denies muscle aches, joint pain, and bone pain
• Normal range of motion throughout

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Neurological

• Alert and oriented to person, place, and time
• Cranial nerves intact
• Motor 5/5 upper and lower extremities bilaterally
• Strength, sensation, and deep tendon reflexes intact and symmetric
• Gait steady
• Tension headache but no dizziness

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Laboratory Blood Test Results

Na                 140 meq/L	Cr                      0.8 mg/dL	PTH              28 pg/mL               Norm (11-54 pg/mL)
K                   3.8 meq/L	Glu, fasting       98 mg/dL	Hb                13.8g/dL
Cl                  100 meq/L	Ca                    11.9 mg/dL	Hct                40.1%
HCO2            25 meq/L	TSH                  0.9 μU/mL                   Norm (0.4- 6μU/mL)	WBC             9.8 x103/mm3
BUN              18 mg/dL	FT4                   2.3 ng/dL               Convert = 29.6 pmol/L               Norm (9-24 pmol/L)	Plt                 250 x103/mm3

Note: Normal values, please refer to Laboratory Values posted on Canvas
Conversion of FT4 from ng/dL x 12.87 to pmol/L.

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Mammography

• (-) Mammogram 2 month ago

Clinical Course

Prior to her referral to the sleep center, a general physical evaluation found Ms. A to be healthy but suffering from excessive sleepiness, fatigue and a lack of energy. A concomitant psychiatric interview revealed high stress but no evidence of depression, anxiety, or other psychopathology. At the sleep center, screens for restless legs syndrome and possible respiratory disturbances were negative. An evaluation of her current lifestyle designed to identify behaviors and thought patterns that might contribute to her insomnia, uncovered situational distress and a weak coping style. The Nurse Practitioner at the clinic went over information in a booklet on “Sleep Hygiene” approaches to regulating sleep. They made an appointment to talk on the phone after 2 weeks. Ms. A also made an appointment with psychiatric nurse practitioner at the clinic to enhance her coping skills and to evaluate the effectiveness of her antidepressant drug.

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Abbreviations