questions 6


Topic updated on 06/14/17 8:57pm


  • A 19-year-old female presents with chronic fatigue. She reports feeling very sleepy throughout the day, has been told that she would doze off, and then eventually drop her head on to the desk. She notes periods of not being able to move after waking up and fell to the ground after being excited at the news of her sister’s pregnancy. What frightened her the most are the vivid “visions” she would get when she is about to fall asleep.  
Sleep Stages
Sleep Stage 
Description EEG Waveform
  • Awake and alert
  • Beta
  • Awake and eyes closed
  • Alpha
Stage N1
  • Light sleep
  • Theta
Stage N2
  • Deeper sleep
  • Sleep spindles and K complexes
Stage N3
  • Deepest non-REM sleep
  • Sleepwalking
  • Night terrors
  • Bedwetting
  • Delta 
  • Dreaming
  • Beta
  • Suprachiasmastic nucleus of the hypothalamus is involved in circadian rhythm regulation
  • GABA agonists (alcohol, benzodiazepines, and barbiturates) reduce REM and delta sleep
REM Sleep
  • Description
    • dreaming
    • loss of motor tone
    • may serve a memory processing function
  • Physiology
    • same EEG pattern as when awake
      • therefore called "paradoxical sleep" or "desynchronized sleep"
    • rapid eye movement
      • defining feature of REM sleep
      • due to activity of paramedian pontine reticular formation
    • erection
    • ↑ and variable pulse and blood pressure
    • loss of muscle tone
  • Neurotransmitters
    • acetylcholine is the principle neurotransmitter
    • norepinephrine, serotonin, and histamine suppress REM sleep
      • therefore, certain antidepressants (eg, SSRI, SNRI) can pharmacologically suppress REM sleep
  • Timing
    • occurs every 90 min
    • duration ↑ with every cycle
    • amount of REM sleep ↓ with age
Sleep Disorders
  • Narcolepsy  
    • disordered regulation of sleep cycles secondary to loss of orexin (hypocretin) neuropeptides
    • excessive daytime sleepiness
    • sleep paralysis
    • may include hallucinations
      • hypnagogic
        • just before sleep
      • hypnopompic
        • just before awakening
    • nocturnal and narcoleptic sleep episodes start off with REM sleep
    • cataplexy
      • loss of all muscle tone following a strong emotional stimulus
      • only some patients
      • patients have undetectable hypocretin-1 in levels in CSF 
    • stong genetic component
    • treat with stimulants 
      • e.g., modafinil (first-line) and amphetamines (generally second-line)
  • Sleep apnea
    • see Sleep Apnea


Qbank (5 Questions)

(M1.NE.73) An 18-year-old man presents to his primary care physician with a complaint of excessive daytime sleepiness. He denies any substance abuse or major changes in his sleep schedule. He reports frequently dozing off during his regular daily activities. On further review of systems, he endorses falling asleep frequently with the uncomfortable sensation that there is someone in the room, even though he is alone. He also describes that from time to time, he has transient episodes of slurred speech when experiencing heartfelt laughter. Vital signs are stable, and his physical exam is unremarkable. This patient is likely deficient in a neurotransmitter produced in which part of the brain? Topic Review Topic

1. Thalamus
2. Pons nucleus
3. Hippocampus
4. Hypothalamus
5. Midbrain

(M1.NE.75) A 19-year-old man is seen by his primary care physician. The patient has a history of excessive daytime sleepiness going back several years. He has begun experiencing episodes in which his knees become weak and he drops to the floor when he laughs. He has a history of marijuana use. His family history is notable for hypertension and cardiac disease. His primary care physician refers him for a sleep study, and which confirms your suspected diagnosis.

Which of the following is the best first-line pharmacological treatment for this patient? Topic Review Topic

1. Dextroamphetamine
2. Lisdexamfetamine
3. Methylphenidate
4. Zolpidem
5. Modafinil

(M1.NE.129) A mother brings her 6-year-old daughter to the pediatrician to discuss her child's sleeping troubles. Three times now in the last month the child has begun screaming and crying in the middle of the night. When the parents rush to the child's room, they find her crying inconsolably. They try to ask her what is wrong, but she does not respond and persists crying for approximately 20 minutes, after which she goes back to sleeping comfortably. Upon awaking the following morning, she has no recollection of the night's events. Which of the following is true about these episodes? Topic Review Topic

1. They will be persistent into adulthood
2. They occur only during non-REM sleep
3. They can occur any time during the sleep cycle
4. They are associated with child abuse
5. They are associated with later development of a mood disorder

(M1.NE.4671) A 23-year-old woman is seen by her primary care physician. The patient has a several year history of excessive daytime sleepiness. She also reports episodes where she suddenly falls to the floor after her knees become weak, often during a laughing spell. She has no other significant past medical history. Her primary care physician refers her for a sleep study, which confirms the suspected diagnosis. Which of the following laboratory findings would also be expected in this patient? Topic Review Topic

1. Increased serum methoxyhemoglobin
2. Reduced serum hemoglobin
3. Undetectable CSF hypocretin-1
4. Increased CSF oligoclonal bands
5. Increased serum ESR

(M1.NE.4754) A mother brings her 7-year-old son to the pediatrician because she is worried about his sleep. She reports that the child has repeatedly woken up in the middle of the night screaming and thrashing. Although she tries to reassure the child, he does not respond to her or acknowledge her presence. Soon after she arrives, he stops screaming and appears confused and lethargic before falling back asleep. When asked about these events, the child reports that he cannot recall ever waking up or having any bad dreams. These events typically occur within four hours of the child going to sleep. The child’s past medical history is notable for asthma and type I diabetes mellitus. He uses albuterol and long-acting insulin. There have been no recent changes in this patient’s medication regimen. His family history is notable for obesity and obstructive sleep apnea in his father. Physical examination reveals a healthy male at the 40th and 45th percentiles for height and weight, respectively. Which of the following EEG waveforms is most strongly associated with this patient’s condition? Topic Review Topic

1. Alpha waves
2. Beta waves
3. Theta waves
4. Delta waves
5. Sleep spindles

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