Sleep Medicine Practice Questions

Q: Non-erosive arthritis is characteristic of which condition?

Systemic Lupus Erythematosus (SLE). Explanation: The hallmark of joint involvement in Systemic Lupus Erythematosus (SLE) is non-erosive arthritis [1]. Unlike inflammatory arthritides that destroy bone and cartilage, SLE involves synovial inflammation that leads to laxity of ligaments and tendons rather than bony destruction. While patients may present with significant deformities (such as Jaccoud’s arthropathy, characterized by ulnar deviation and swan-neck deformities), these are typically reducible because the underlying joint surface remains intact on X-ray. Analysis of Incorrect Options: * Rheumatoid Arthritis (RA): This is the prototype of erosive arthritis [2]. Chronic synovial pannus formation leads to marginal bony erosions and joint space narrowing, resulting in permanent, non-reducible deformities. * Psoriasis (Psoriatic Arthritis): Characterized by aggressive bone involvement. Radiographic features include "pencil-in-cup" deformities and marginal erosions, often leading to joint destruction (Arthritis mutilans) [1]. * Gout: Chronic tophaceous gout causes "punched-out" erosions with overhanging edges (Martel’s sign) due to the deposition of monosodium urate crystals in and around the joint. NEET-PG High-Yield Pearls: * Jaccoud’s Arthropathy: Classic "reversible" deformity seen in SLE (and Rheumatic Fever). * Most common joint involved in SLE: Small joints of the hands (PIP, MCP) and wrists, usually symmetrical [1]. * X-ray finding in SLE: Soft tissue swelling and periarticular osteopenia, but no marginal erosions. * Synovial fluid in SLE: Usually mildly inflammatory (WBC count <2000–5000/mm³).

Q: Sleep apnea is defined as a temporary pause in breathing during sleep lasting at least:

10 seconds. **Explanation:** **1. Why Option D is Correct:** In clinical sleep medicine, an **apnea** is defined as a complete or near-complete (≥90%) cessation of airflow at the nose and mouth for a duration of **at least 10 seconds** [1]. This 10-second threshold is the standardized diagnostic criterion used in Polysomnography (PSG) to identify clinically significant respiratory events. These pauses are often associated with oxygen desaturation or cortical arousals, leading to fragmented sleep [2]. **2. Why Other Options are Incorrect:** * **Options A (40s) and B (30s):** While apneic episodes can certainly last this long (and are often more severe when they do), they are not the *minimum* requirement for diagnosis. Using these as a baseline would significantly under-diagnose patients with Obstructive Sleep Apnea (OSA). * **Option C (20s):** This is a common distractor. While 20 seconds is a threshold often used in **neonatal medicine** to define apnea of prematurity (or shorter if accompanied by bradycardia/cyanosis), the standard adult definition remains 10 seconds. **3. High-Yield Clinical Pearls for NEET-PG:** * **Apnea-Hypopnea Index (AHI):** This is the gold standard for grading OSA severity [2]. It is calculated as the (Total number of Apneas + Hypopneas) / Total Sleep Time (in hours). * *Mild:* 5–15 events/hr * *Moderate:* 15–30 events/hr * *Severe:* >30 events/hr * **Hypopnea:** Defined as a ≥30% reduction in airflow for ≥10 seconds, accompanied by ≥3% oxygen desaturation or an arousal. * **Gold Standard Investigation:** Polysomnography (Level 1 study). * **Treatment of Choice:** Continuous Positive Airway Pressure (CPAP) [2]. * **Common Association:** Pickwickian Syndrome (Obesity Hypoventilation Syndrome) characterized by obesity, daytime hypercapnia, and sleep-disordered breathing.

Q: An obese, diabetic patient with hypertension, who is also a smoker and currently on anti-hypertensive and oral hypoglycemic drugs, presents with complaints of apnea during sleep. Polysomnography reveals 5 apneic episodes and 1 hypopneic episode per hour. What is the best next line of management?

Diet and weight reduction. ### Explanation The patient presents with symptoms suggestive of Obstructive Sleep Apnea (OSA). However, the diagnosis and management of OSA are strictly guided by the **Apnea-Hypopnea Index (AHI)**, which is the number of apnea and hypopnea episodes per hour of sleep [1]. **1. Why "Diet and weight reduction" is correct:** In this case, the patient’s AHI is **6** (5 apneas + 1 hypopnea). According to clinical guidelines: * **Normal:** AHI 30 Since the patient falls into the **Mild OSA** category and possesses multiple reversible risk factors (obesity, smoking), the initial management is **conservative lifestyle modification** [1]. Weight loss is the most effective non-device intervention to reduce pharyngeal collapsibility and improve AHI [3]. **2. Why other options are incorrect:** * **Nasal CPAP:** This is the "Gold Standard" treatment for OSA [1], but it is typically indicated for **Moderate to Severe OSA** (AHI > 15) or Mild OSA (AHI 5–15) only if the patient has significant symptoms (daytime sleepiness) or co-morbidities like cardiovascular disease [2]. * **Uvulopharyngopalatoplasty (UPPP):** This is a surgical intervention reserved for patients who fail CPAP or have specific anatomical obstructions. It is not a first-line treatment. * **Mandibular sling/Advancement Devices:** These are oral appliances used for mild-to-moderate OSA in patients who cannot tolerate CPAP, but they follow lifestyle modifications. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Overnight Polysomnography. * **Gold Standard Treatment:** Nasal CPAP (Continuous Positive Airway Pressure) [2]. * **Pickwickian Syndrome:** Obesity Hypoventilation Syndrome (BMI > 30 + daytime hypercapnia PaCO2 > 45 mmHg). * **Mallampati Score:** Used to assess the airway; high scores (III and IV) are associated with an increased risk of OSA.

Q: Identify the sleep stage in the following Polysomnograph.

NREM stage 2. ***NREM stage 2*** - The **EEG** shows prominent **sleep spindles** (bursts of 12-14 Hz waves) and **K-complexes** (high-amplitude biphasic waves), which are characteristic features of NREM stage 2 sleep. - The EOG channels indicate slow eye movements or an absence of rapid eye movements, consistent with NREM sleep, while the **EMG shows moderate muscle tone**, higher than in REM sleep but lower than wakefulness. *NREM stage 3* - This stage is characterized by **delta waves**, which are slow waves with high amplitude (0.5-2 Hz, often >75 μV) on the EEG, comprising 20% or more of the epoch, and are not significantly visible here. - While muscle tone is still present, the EEG would primarily show widespread **slow-wave activity**, distinguishing it from the sleep spindles and K-complexes seen in the image. *REM* - **Rapid eye movements** would be clearly visible on the EOG channels, which are not prevalent in this polysomnograph. - The **EMG would show very low muscle tone** (atonia), which is not the case here, and the EEG would largely consist of low-voltage, mixed-frequency activity, similar to wakefulness. *NREM stage 1* - This stage is typically characterized by a **disappearance of alpha waves** from the EEG and the presence of **theta waves** (4-7 Hz). - While there may be slow eye movements on the EOG, **sleep spindles and K-complexes are absent** in NREM stage 1, making it distinct from the presented polysomnograph.

Q: A 40-year-old man presents with daytime sleepiness and impaired concentration and memory. On examination his BMI is 41 kg/m2, BP is 160/100 mm Hg. His awake ABG analysis is given: PaO2=66 mm Hg, PaCO2=50 mm Hg, HCO3=28 mEq/L. What is the most likely diagnosis?

Obstructive sleep apnea. ***Obstructive Sleep Apnea (Correct Answer)*** - Classic triad: **morbid obesity (BMI 41 kg/m²)**, **excessive daytime somnolence**, and **systemic hypertension (160/100 mmHg)** — hallmarks of OSA - **ABG findings** (PaO2=66 mmHg, PaCO2=50 mmHg, HCO3=28 mEq/L) indicate **chronic nocturnal hypoxemia and hypercapnia** with compensatory **metabolic alkalosis** from repeated apneic episodes - **Cognitive impairment** (impaired concentration and memory) results from **sleep fragmentation** and intermittent nocturnal hypoxia - Obesity promotes **pharyngeal fat deposition** → upper airway narrowing and collapse during sleep → recurrent obstructive events *Narcolepsy* - Causes excessive daytime sleepiness but is **not associated with obesity, hypertension, or ABG abnormalities** - Hallmarks include **cataplexy**, sleep paralysis, and hypnagogic/hypnopompic hallucinations — none present here - Caused by **orexin (hypocretin) deficiency**; associated with **HLA-DQB1*06:02**; ABG is normal *Obesity Hypoventilation Syndrome (OHS / Pickwickian Syndrome)* - Defined as **awake PaCO2 >45 mmHg + BMI >30 kg/m²** with exclusion of other causes of hypoventilation - OHS frequently coexists as an **overlap with and consequence of severe OSA** rather than being the primary diagnosis - In this setting, **OSA is the most prevalent and primary diagnosis**; OHS is specifically considered when awake hypoventilation persists despite adequate OSA treatment *Central Sleep Apnea* - Results from **failure of central respiratory drive** (brainstem), not upper airway obstruction - Associated with **congestive heart failure, opioid use, high-altitude exposure, or neurological disease** — none present here - Not characteristically associated with morbid obesity; clinical and ABG picture here favors an **obstructive** rather than central pattern

Q: The sleep apnea syndrome is defined as -

Apnea-Hypopnea Index (AHI) ≥ 5/hour. ***Apnea-Hypopnea Index (AHI) ≥ 5/hour*** - The definition of **sleep apnea syndrome** generally requires an **AHI of 5 or more events per hour**, often accompanied by symptoms like excessive daytime sleepiness or cardiovascular complications [1]. - This threshold identifies individuals with clinically significant sleep-disordered breathing that warrants further evaluation and potential treatment [1]. *Apnea-Hypopnea Index (AHI) ≥ 10/hour* - While an AHI of 10/hour indicates sleep apnea, it is a higher severity criterion and does not represent the **minimum threshold** for defining the syndrome [1]. - Patients with an AHI between 5 and 10 also have sleep apnea and can experience significant symptoms. *Apnea-Hypopnea Index (AHI) ≥ 30/hour* - An AHI of 30/hour or more signifies **severe sleep apnea**, which requires aggressive management. - This is far above the **general diagnostic threshold** for sleep apnea syndrome. *Apnea-Hypopnea Index (AHI) ≥ 15/hour* - An AHI of 15/hour is typically classified as **moderate sleep apnea**. - This value is higher than the **lowest AHI threshold** used to define the presence of sleep apnea syndrome.

Q: What is the minimum diagnostic threshold for obstructive sleep apnoea according to current guidelines?

AHI >30 events per hour. AHI >30 events per hour - An Apnoea-Hypopnoea Index (AHI) greater than 30 events per hour indicates severe obstructive sleep apnea (OSA), which is definitively above the minimum diagnostic threshold [1]. - While an AHI of 5 or more is generally considered diagnostic for OSA, an AHI >30 signifies severe disease and often leads to more pronounced symptoms and health risks [1]. *AHI <5 events per hour* - An AHI score of less than 5 events per hour is typically considered normal or within the non-pathological range for sleep-disordered breathing [1]. - Individuals with an AHI below this threshold usually do not meet the diagnostic criteria for any form of sleep apnea. *AHI 15-30 events per hour* - This range indicates moderate obstructive sleep apnea. While it is diagnostic for OSA, it is not the minimum threshold [1]. - Patients in this category often experience significant symptoms and may require treatment, but it is not the lowest AHI at which a diagnosis can be made. *AHI 5-15 events per hour* - This AHI range is considered mild obstructive sleep apnea. An AHI of 5 or more, accompanied by relevant symptoms, is generally the minimum diagnostic threshold for OSA [1]. - However, the question asks for the minimum diagnostic threshold, and while 5 events per hour is a minimum, "AHI >30 events per hour" indicates a clear and severe diagnostic case.

Q: Muller's manoeuvre is used to

To find degree of obstruction in sleep disordered breathing. ***To find degree of obstruction in sleep disordered breathing*** - **Muller's manoeuvre** is a diagnostic technique where the patient attempts to inspire forcefully against a **closed mouth and nostrils** while an endoscope observes the upper airway. - This maneuver helps to simulate the negative intraluminal pressure that occurs during sleep, making it useful in identifying the **site and severity of airway obstruction** in patients with sleep-disordered breathing. *To remove foreign body from ear* - Removing foreign bodies from the ear typically involves **irrigation**, specialized instruments (e.g., alligator forceps), or suction, not a breathing maneuver. - This option is unrelated to the physiological assessment of airway obstruction. *To remove laryngeal foreign body* - The primary methods for removing laryngeal foreign bodies are the **Heimlich maneuver** (abdominal thrusts) or direct laryngoscopy and removal. - Muller's manoeuvre is a diagnostic procedure, not a therapeutic one for foreign body extraction. *To find out opening of mouth* - Measuring the **opening of the mouth** is typically done with a ruler or specific instruments to assess jaw mobility (e.g., for temporomandibular joint disorders or trismus). - This is a simple measurement and does not involve the complex physiological assessment of the upper airway that Muller's manoeuvre provides.

Q: A 32-year-old patient with Restless leg syndrome comes to the OPD. What is the most appropriate first line treatment?

Gabapentin. ***Gabapentin*** - **Gabapentin** and other alpha-2-delta ligands (e.g., pregabalin) are considered **first-line agents** for moderate to severe Restless Legs Syndrome (RLS), particularly when symptoms are bothersome and daily. - They work by modulating **calcium channels** and are effective in reducing RLS symptoms with a generally favorable side effect profile. *Iron Supplementation* - **Iron supplementation** is appropriate as first-line treatment only if **serum ferritin levels** are below 75 mcg/L, indicating iron deficiency. - While RLS is associated with **iron deficiency**, it's not the universal first-line treatment without biochemical confirmation [1]. *Pramipexole* - **Dopamine agonists** like pramipexole are effective for RLS but are generally **second-line treatments** due to concerns about augmentation (worsening of RLS symptoms) and impulse control disorders. - Augmentation is a significant side effect where symptoms worsen paradoxically with continued use, particularly with higher doses. *Vitamin B12* - **Vitamin B12 deficiency** can cause neurological symptoms, but it is **not a primary cause or treatment** for Restless Legs Syndrome. - Supplementation with **Vitamin B12** would only be considered if a confirmed deficiency exists, which is not stated as a contributing factor in this patient.

Question 1

Non-erosive arthritis is characteristic of which condition?

Accepted Answer

Systemic Lupus Erythematosus (SLE)

Answer

Psoriasis

Answer

Rheumatoid Arthritis (RA)

Answer

Gout

Question 2

Sleep apnea is defined as a temporary pause in breathing during sleep lasting at least:

Accepted Answer

10 seconds

Answer

40 seconds

Answer

30 seconds

Answer

20 seconds

Question 3

An obese, diabetic patient with hypertension, who is also a smoker and currently on anti-hypertensive and oral hypoglycemic drugs, presents with complaints of apnea during sleep. Polysomnography reveals 5 apneic episodes and 1 hypopneic episode per hour. What is the best next line of management?

Accepted Answer

Diet and weight reduction

Answer

Nasal CPAP

Answer

Uvulopharyngopalatoplasty

Answer

Mandibular sling

Question 4

Identify the sleep stage in the following Polysomnograph.

Accepted Answer

NREM stage 2

Answer

NREM stage 3

Answer

REM

Answer

NREM stage 1

Question 5

A 40-year-old man presents with daytime sleepiness and impaired concentration and memory. On examination his BMI is 41 kg/m2, BP is 160/100 mm Hg. His awake ABG analysis is given: PaO2=66 mm Hg, PaCO2=50 mm Hg, HCO3=28 mEq/L. What is the most likely diagnosis?

Accepted Answer

Obstructive sleep apnea

Answer

Narcolepsy

Answer

Obesity hypoventilation syndrome

Answer

Central sleep apnea

Question 6

A 45-year-old obese man presents to his primary care provider for an annual physical. The patient states that he has noticed increased sleepiness during the day at work over the past 6 months in addition to difficulty concentrating and worsening memory. He denies recent weight loss, and is not sure if he snores because he sleeps by himself. His past medical history is significant for hypertension and type II diabetes. Vital signs are T 98.6 F, HR 75 bpm, BP 140/90 mm Hg, RR 18/min. Physical exam reveals a 350 pound man. Jugular venous distension is difficult to evaluate due to excess tissue in the neck. There is no peripheral edema. Lung exam is normal. Routine CBC shows WBC count of 5000 cells/ml, platelet count of 350,000/mcL, hemoglobin of 18 gm/dL, and hematocrit of 54%. What is the most likely cause of his abnormal lab results?

Accepted Answer

Sleep apnea

Answer

JAK2 mutation

Answer

Malignancy

Answer

Cor pulmonale

Answer

Diuretic overuse

Question 7

The sleep apnea syndrome is defined as -

Accepted Answer

Apnea-Hypopnea Index (AHI) ≥ 5/hour

Answer

Apnea-Hypopnea Index (AHI) ≥ 10/hour

Answer

Apnea-Hypopnea Index (AHI) ≥ 30/hour

Answer

Apnea-Hypopnea Index (AHI) ≥ 15/hour

Question 8

What is the minimum diagnostic threshold for obstructive sleep apnoea according to current guidelines?

Accepted Answer

AHI >30 events per hour

Answer

AHI <5 events per hour

Answer

AHI 15-30 events per hour

Answer

AHI 5-15 events per hour

Question 9

Muller's manoeuvre is used to

Accepted Answer

To find degree of obstruction in sleep disordered breathing

Answer

To remove foreign body from ear

Answer

To remove laryngeal foreign body

Answer

To find out opening of mouth

Question 10

A 32-year-old patient with Restless leg syndrome comes to the OPD. What is the most appropriate first line treatment?

Accepted Answer

Gabapentin

Answer

Iron Supplementation

Answer

Pramipexole

Answer

Vitamin B12

Sleep Medicine — MCQs

Sleep Medicine — MCQs

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