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Probability diagnosis

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Stress and anxiety

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Depression

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Inappropriate sleep hygiene or lifestyle

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Environmental e.g. noisy household

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Drug withdrawal inc. alcohol, hypnotics

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Biorhythm disruption e.g. shift work, travel

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Serious disorders not to be missed

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Vascular:

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  • Peripheral vascular disease

  • Congestive cardiac failure

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Tumours:

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  • Pharyngeal

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Other:

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  • Pain syndromes e.g. back, arthritis, CTS, cancer

  • Respiratory e.g. asthma, COPD, nasal obstruction

  • Post traumatic stress disorder

  • Psychosis

  • Restless legs/nocturnal myoclonus

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Pitfalls (often missed)

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Sleep apnoea

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GORD

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Dementia

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Menopausal symptoms

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Rarities:

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  • Macroglossia/tonsillar hypertrophy

  • Malnutrition

  • Parasomnias e.g. night terrors

  • Malnutrition

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Masquerades checklist

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Depression

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Diabetes

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Drugs: stimulants, alcohol, beta blockers, SSRIs, steroids

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Thyroid/other endocrine: hyperthyroid

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Spinal dysfunction

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Urinary tract infection: nocturia

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Is the patient trying to tell me something?

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A consideration if nil findings.

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Some cases are normal variant or idiopathic.

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Key history

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A careful history is required because some patients have unrealistic expectations about the required amount of sleep they need or have misperceptions of how long they have slept. Explore lifestyle factors esp. psychosocial reasons, painful conditions, drug use and abuse, appetite, energy, sexual issues and physical factors. Examine past medical history including diabetes, hypertension and cerebrovascular disease, as well as drug history, esp. alcohol. Check thyroid status, esp. hyperthyroidism.

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Key examination

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  • General features: appearance of patient, vital signs including BMI, inspection of the nasal passages, throat and neck (goitre)

  • General respiratory and cardiovascular examination

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Key investigations

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Nil for most cases. Others according to history and findings.

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Consider:

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  • FBE

  • ESR/CRP

  • LFTs (γGT)

  • TFT

  • sleep studies

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Diagnostic tips

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Pay close attention to drugs use, esp. alcohol, caffeine, narcotics, illicit agents, SSRIs, benzodiazepines, and esp. if desperate request for drugs.

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Be aware of the effects of ageing including carpal tunnel syndrome, arthritis, prostate problems and incontinence.

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