A 52-year-old man comes to the office due to difficulty falling asleep, frequent nighttime awakenings, and daytime fatigue for the past several months. It takes him over an hour to fall asleep, and he often awakens at 2 AM and again at 4 AM. During the day, the patient struggles to stay awake during long staff meetings. He experiences no snoring, shortness of breath, or chest pain. The patient recently went through a divorce and is under financial pressure to make childcare payments. He has a history of hypertension and hypercholesterolemia. Family history is significant for coronary artery disease and emphysema. The patient smokes a pack of cigarettes a day. He drinks 2 or 3 cups of coffee every morning, an energy drink in the afternoon 1 or 2 days a week, and a beer with dinner.
On physical examination, blood pressure is 125/78 mm Hg and pulse is 74/min. BMI is 30 kg/m². The remainder of the examination is normal.
Laboratory studies include a hematocrit of 43%, a leukocyte count of 5,300/mm³, a fasting plasma glucose of 100 mg/dL, and a serum TSH level of 2.3 µU/mL. Results of a chest radiograph and ECG are normal.
Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

Depression is a common and treatable cause of sleep disturbance and fatigue and is diagnosed clinically. Patients with insomnia and fatigue that do not appear to be secondary to a medical condition, a sleep disorder, or substances should first be evaluated for major depression. This patient with initial and middle insomnia and fatigue in the context of recent psychosocial stressors should undergo depression screening. The patient should be asked about his mood, interest, and ability to feel pleasure in activities and screened for depressive symptoms such as appetite disturbance, impaired concentration, pessimism, excessive guilt, and suicidal ideation. If a diagnosis of major depressive disorder is confirmed, treatment with antidepressants and/or psychotherapy is indicated. Additional testing may be indicated if sleep disturbance does not improve with adequate treatment of depression. (Choices A and E) This patient has risk factors for cardiac disease (ie, sex, age, smoking, obesity, hypertension, hypercholesterolemia) and pulmonary disorders (ie, smoking, obesity); however, he does not have symptoms or findings indicative of coronary artery disease (CAD) or chronic obstructive pulmonary disease (COPD). Therefore, further evaluation for COPD with spirometry or stress testing for CAD is not indicated at this time. (Choice C) The multiple sleep latency test, which evaluates sleep latency and sleep-onset REM periods, would be indicated if narcolepsy were suspected. It is not typically indicated in the diagnostic evaluation of insomnia. (Choice D) Although this patient has risk factors for sleep apnea (ie, sex, hypertension, obesity), he does not report other characteristic features such as snoring and breathing pauses. Depression screening should take precedence; if it is negative, polysomnography could then be considered. Educational objective: Depression is a common and treatable cause of sleep disturbance and fatigue. All patients presenting with these symptoms should undergo depression screening. __________ References: Sleep disturbances in mood disorders. (http://www.ncbi.nlm.nih.gov/pubmed/26600106) Inquiring about insomnia may facilitate diagnosis of depression in the primary care setting. (http://www.ncbi.nlm.nih.gov/pubmed/28094458)

A 52-Year-Old Man Comes to the Office Due to Difficulty