Who you are:
You are an FY2 doctor in medicine.Who your patient is:
Mrs. Elissa Banks, aged 32, came to the hospital with insomnia.What your task is:
Please talk to patient and address her concerns.
P1
D: What brought you to the hospital?
P: I have trouble sleeping.
D: Please tell me more about it.
P: (Let her speak)
D: When did this problem start?
P: It started a few months ago.
D: Do you have trouble getting to sleep or do you wake up in the middle of the night?
P: I have trouble in going to sleep.
D: What time you go to bed?
P: I go to bed around 10pm.
D: What time you usually go to sleep?
P: I go to sleep around 2 am. Sometimes I don’t sleep all night.
D: What time do you usually wake up?
P: I wake up around 8am.
D: Do you wake up during your sleep?
P: No.
D: How was your sleep before this problem started?
P: It was fine.
D: Do you take any naps during the day?
P: No.
D: Anything else?
P: No.
D: Can you think of anything which might be the cause of your problem?
P: No.
D: Tell me what you do before you go to bed?
Patient is anxious and shaking too much in the station. We need to make he comfortable. After that she will open up
D: Are you comfortable? Or is anything bothering you?
P: Is this conversation confidential?
D: Yes, it is confidential.
P: I am having problems with my husband.
D: Could you please tell me more about it?
P: He got violent with me.
D: When did that happen?
P: It happened few days ago.
D: Has it happened before?
P: Yes it has happened many times.
D: How long have you been together?
P: 1 year.
D: Does he have any mental health problems?
P: No.
D: Was he under the influence of alcohol or drugs when he hit you?
P: No.
D: Does he have any criminal record?
P: No.
D: Do you have any injuries from him that you would like me to look at?
P: No it’s OK.
D: Is there anyone else living with you? Any children?
P: No.
D: Any relative nearby?
P: No.
You want to complete your history, but halfway through she has just made a
shocking revelation about her husband. What about your history? You can
say this:
D: What you are saying about your husband is probably linked to your
insomnia. But just so that I can get a complete medical picture about you,
without jumping to a diagnosis prematurely, is it OK if I finish asking you
these health questions and then we can address this issue better? (You can
say this, so she doesn’t think you have just casually dismissed her revelation
to you by moving on to other questions that have nothing to do with her
husband.)
P: Yes OK.
MOOD
D: How is your mood?
P: It is okay.
D: Could you please score the mood on a scale of 1 to 10, where 1 is lowest and 10 being the highest.
P: It’s low doctor like 3-4.
Suicide
D: Do you feel suicidal/Like hurting yourself? (Signpost first)
P: No.
F (Friend, Family, Finance)
D: What do you do for a living?
P: I work in landscape gardening.
D: Do you have any friends?
P: I have a few friends around.
D: Did you discuss it with them?
P: No.
P2 (Medical and Mental History)
D: Any fever, flu, or cough?
P: No.
D: Any problem with urine or bowels?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any asthma?
P: No.
D: Are you taking any other medications including OTC or supplements?
P: No.
P3 (DESA)
Ask about tea or coffee? How much? When you take last cup? Smoking.
Alcohol. Recreational drug, stress. Watching TV etc. Noisy environment
Impact and Insight
D: Do you think your sleeping problems are because of this ongoing issue with your husband?
P: Yes. I think so.
Examination:
Is it OK if I check your vitals and do a general physical examination to see if everything is alright? —Normal
Management:
NAI and depression are the most common causes for insomnia.
- Admit for NAI in elderly and children, or depression with suicidal thoughts.
- If a child is involved, do not forget to raise concerns with your senior, so social services can interfere to assess the situation.
- If in adult, like in this case, offer social services referral for support with an accommodation, financial support, support for job search to achieve independence.
D: The incident you told me about with your husband is illegal. You don’t need to put up with this. There are some ways that we can help and support you. There is a designated person in the hospital who deals with these issues. We can arrange a meeting with that person. He will explain about the services that are available to help people in your situation. Don’t worry. My colleague will refer you to an organisation - MARAC (A Multi Agency Risk Assessment Conference) and they will support you.
P: I am afraid to go home.
D: The police and social services will be involved, you don’t have to worry about anything.
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Talk to my senior.
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Investigations: Basic bloods for physical cause (FBC, FBS, TFT, LFT, KFT, TFT, vitamin levels) *urine screen/dip for infection/drug screen. If NAI/injury, investigate it by doing an X-ray, clotting factors- skeletal survey- fundoscopy- CT head.
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Symptomatic & lifestyle management: Sleep hygiene: avoid caffeinated drinks, recreational drugs, avoid heavy meals, alcohol, smoking and exercise before bedtime. Avoid taking naps in daytime. If shift worker, think about changing the job or speaking to your supervisor to organize your rota so you can be consistent in consecutive shifts without major fluctuations in sleep schedule
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Specialist: according to the cause (NAI, raise concern with your senior so he/she can contact the social services, if depression, manage with CBT, anti-depressants and/or psychiatrist referral, etc.)
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Safety netting for persistent insomnia that is not managed by the above measures and for complications (for example, if depressed or NAI, for low mood and suicidal thoughts).
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Follow up.
If patient asks for sleeping pill
- Ask why?
- Address the concerns.
- Offer other solutions.
- Say it is addictive and it may cause rebound insomnia when
stopped, so it is not a long-term solution. - It could be an option only if these solutions fail, only for
short-term after consulting with your senior.