Sleep Disturbance
Sleep disturbance is a broad term encompassing any alteration in normal sleep patterns, including difficulty initiating or maintaining sleep, excessive sleepiness, or abnormal behaviors during sleep, that impairs daytime functioning.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Poor sleep hygiene / inadequate sleep | Irregular schedule, caffeine, screens, naps | 「你幾點上床？瞓之前做啲咩？」 | ~35% |
| Chronic insomnia disorder | ≥ 3 mo, ≥ 3×/wk, impaired daytime function, no adequate explanation [1] | 「瞓唔到有冇超過三個月？一個禮拜三晚以上？」 | ~25% | |
| Serious Not To Miss | Major depressive disorder | Low mood + anhedonia + early-morning waking ≥ 2 weeks [4] | 「你有冇成日唔開心、冇興趣做嘢、早朝好早醒？」 | ~15% |
| Obstructive sleep apnoea (OSA) | Snoring + witnessed apnoea + EDS + obesity; AHI on polysomnography [2][3] | 「有冇鼻鼾？有冇人話你停咗呼吸？日頭好眼瞓？」BMI, neck circumference | ~10% | |
| Suicidal ideation (in depression/anxiety) | Active thoughts of self-harm | 「有冇諗過傷害自己？」 | ~3% | |
| Pitfalls | Chronic pain (MSK, neuropathic) | Pain prevents sleep onset or causes awakening | 「有冇邊度痛影響你瞓覺？」 | ~10% |
| Circadian rhythm disorder (shift work / delayed sleep phase) | Sleep normal but at wrong time; shift worker | 「你有冇輪班？邊個時間先至瞓得着？」 | ~5% | |
| Restless leg syndrome | Urge to move legs at rest, evening predominance, relieved by movement [1] | 「瞓覺前對腳有冇好唔舒服、好想郁、郁完舒服啲？」 | ~3% | |
| Masquerades | Depression | Classic masquerade; early-morning waking pattern [4] | 「心情點？胃口點？體重有冇變？」 | ~15% |
| Drugs / substances | Caffeine, alcohol, stimulants, steroids, β-agonists [1][2] | 「你有冇飲咖啡、酒、食咩藥？」 | ~10% | |
| Thyroid disease (hyperthyroidism) | Insomnia + weight loss + tremor + palpitations | 「有冇心跳快、手震、怕熱、瘦咗？」 | ~2% | |
| Anaemia | Fatigue, RLS-like symptoms if iron-deficient | 「有冇面青、好攰？」 | ~2% | |
| Trying to Tell Me Something? | Psychosocial stress / anxiety / hidden agenda | Work pressure, relationship conflict, financial worry, health anxiety | 「最近生活有冇咩令你好大壓力？你今日嚟最擔心嘅係咩？」 | ~30% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, open question | 「你好，我係XX醫生，今日想同你傾下，請問你今日嚟有咩唔舒服呀？」(Hello, I'm Dr XX, what brings you in today?) | Friendly opening scores interpersonal marks. Open question lets patient talk freely. |
| 0:30–1:30 | HPI: characterise the sleep disturbance | 「你瞓唔着係瞓唔入定半夜醒咗？幾耐㗎喇？一個禮拜有幾多晚？日頭有冇好攰好眼瞓？」(Is it trouble falling asleep or waking up? How long? How many nights/week? Daytime sleepiness?) | Defines insomnia subtype (initial / maintenance / early-morning waking). Quantifies severity & duration. |
| 1:30–2:30 | Red flags + key DDx screening | 「你有冇鼻鼾、半夜透唔到氣？枕邊人有冇話你瞓覺停過呼吸？心情點呀，有冇唔開心或者成日擔心？有冇腳郁嚟郁去瞓唔到？有冇食咩藥或者飲咖啡茶酒？」(Snoring/apnoea? Mood? Restless legs? Medications/caffeine/alcohol?) | Screens OSA, depression, anxiety, RLS, substances – the top DDx that examiners expect. |
| 2:30–3:30 | PMH, FH, social Hx, occupation, functional impact | 「你有冇長期病？食緊咩藥？做咩工嚟㗎？瞓唔好有冇影響你返工或者揸車？屋企有冇咩壓力？」(Chronic illness? Meds? Occupation? Impact on work/driving? Stress at home?) | Biopsychosocial data directly feeds Q5b. Driving/machinery = safety issue scores extra marks. |
| 3:30–4:30 | ICE (Ideas, Concerns, Expectations) | 「你自己覺得點解會瞓唔到呀？」(What do you think is causing it?) 「你最擔心啲咩？」(What worries you most?) 「你嚟今日最希望醫生可以點幫你？」(What were you hoping I could do for you today?) | ICE is a dedicated CRF section. Ask all three explicitly. |
| 4:30–5:15 | Signpost, summarise, check understanding | 「等我總結下：你話瞓唔入已經兩個月，日頭好攰，影響返工，你擔心係咪有咩大病。我有冇漏咗啲咩？」 | Summarising back shows active listening; checking understanding scores highly. |
| 5:15–6:00 | Brief plan + safety net + close | 「我哋可以先做少少檢查同埋傾下生活習慣點改善，有需要可以轉介。如果你覺得情緒好差或者有傷害自己嘅念頭，記住即刻嚟急症室或者打熱線。你仲有冇嘢想問？」 | Closes safely with safety net. Screens briefly for suicidal ideation if mood issue surfaced – a must-not-miss. |
Uncovering the hidden agenda: The surface complaint is "can't sleep," but the real reason may be anxiety about a stressful event (e.g., job loss, marital conflict), fear of a serious illness, or wanting sleeping pills. Always ask 「點解你今日先嚟睇呀？」(Why did you come specifically today?) and 「你最擔心啲咩？」 to reveal the true reason for consultation.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & Duration | When did the sleep problem start? How long? | 「幾時開始瞓唔到？有幾耐㗎喇？」 | Acute ( < 3 mo) vs chronic insomnia (≥ 3 months, ≥ 3 nights/week) [1] | Chronic insomnia disorder if ≥ 3 mo |
| Type | Trouble falling asleep, staying asleep, or waking too early? | 「你係瞓唔入、定半夜醒咗瞓唔返、定好早醒？」 | Difficulty initiating (≥ 30 min), maintaining (≥ 30 min awake), or early-morning wakening [1] | Initial = anxiety/poor hygiene; Early-morning = depression; Maintenance = OSA/pain |
| Frequency | How many nights per week? | 「一個禮拜大約幾多晚係咁？」 | DSM-5 insomnia: ≥ 3 nights/week [1] | |
| Daytime impact | Daytime sleepiness? Fatigue? Concentration? | 「日頭有冇好攰、冇精神、做嘢集中唔到？」 | Compromised daytime function required for diagnosis [1]; sleepiness vs fatigue differentiation [2] | Sleepiness during sedentary = OSA; Fatigue on exertion = medical cause |
| Snoring/Apnoea | Do you snore? Has anyone seen you stop breathing? | 「你有冇鼻鼾？有冇人話你瞓覺時停咗呼吸？」 | Snoring + witnessed apnoea → OSA [2][3] | OSA – screen BMI, neck circumference |
| Mood | Feeling low/sad? Lost interest? Anxious/worried a lot? | 「你心情點？有冇成日唔開心或者冇晒興趣？有冇成日好擔心好緊張？」 | Depression & anxiety are top comorbidities and masquerades [4] | Depression (early-morning waking + low mood); GAD (initial insomnia + worry) |
| Suicidal ideation | Any thoughts of harming yourself? | 「有冇諗過傷害自己或者唔想活？」 | Must-not-miss if mood screening positive [5] | Urgent psychiatric referral |
| Restless legs | Uncomfortable urge to move legs at night? | 「瞓覺前對腳有冇唔舒服、好想郁？」 | RLS: unpleasant urge to move legs during inactivity, esp evening, relieved by movement [1] | RLS / PLMD – check iron deficiency |
| Sleep hygiene | Caffeine/tea/phone/nap/irregular schedule? | 「你瞓之前有冇飲咖啡茶、碌電話、瞓晏覺？幾點上床幾點起身？」 | Poor sleep hygiene is the #1 modifiable factor | Primary insomnia / inadequate sleep hygiene |
| Substances | Alcohol, smoking, recreational drugs, sleeping pills? | 「有冇飲酒、食煙、食安眠藥或者其他藥？」 | Drugs, alcohol, hypnotics are key precipitants [1][2] | Substance-induced; rebound insomnia |
| Medications | Current medications? Steroids, beta-blockers, SSRI, theophylline? | 「你依家有冇食緊咩藥？」 | Many drugs cause insomnia (steroids, β-blockers, theophylline, decongestants) | Drug-induced insomnia |
| PMH | Chronic pain, asthma, GERD, thyroid, heart failure? | 「你有冇長期病？痛症、氣管、胃酸倒流、甲狀腺？」 | Medical conditions causing secondary insomnia | Specific disease-related insomnia |
| Nocturia | Getting up to pass urine at night? | 「你半夜要起身去廁所幾多次？」 | Nocturia (BPH, DM, HF) disrupts sleep | BPH, poorly controlled DM, HF |
| FH | Family history of sleep problems, mental illness? | 「屋企人有冇瞓唔到或者精神健康問題？」 | Familial insomnia; RLS runs in families | |
| Occupation & Safety | Job? Shift work? Drive or operate machinery? | 「做咩工？有冇輪班？有冇揸車或者操作機器？」 | Shift-work disorder; safety risk assessment [2] | Circadian rhythm disorder; urgent if drives drowsy |
| Stressors | Any stress at work/home/relationships? | 「最近有冇咩壓力？工作、屋企、感情？」 | Psychosocial stressor is the most common trigger for acute insomnia [4] | Adjustment insomnia; hidden agenda |
| Menopause (if female ≥ 40) | Hot flushes? Periods changed? | 「有冇潮熱、冇咗月經？」 | Climacteric symptoms cause sleep disturbance [6] | Menopausal insomnia |
| Epworth scale (brief) | Would you fall asleep reading/watching TV/sitting? | 「你坐喺度睇電視或者睇書會唔會瞓著咗？」 | Epworth Sleepiness Scale quantifies daytime sleepiness [2] | Score > 10 suggests significant sleepiness → OSA |
Case Report Form Answer Builder
- CC: Insomnia / sleep disturbance × [duration]
- HPI high-yield points to capture:
- Type: difficulty initiating / maintaining / early-morning waking
- Duration & frequency (≥ 3 mo, ≥ 3×/wk → chronic)
- Daytime consequence: fatigue, poor concentration, EDS
- Aggravating factors: stress, caffeine, screen use, shift work
- Associated symptoms: snoring/apnoea (→ OSA), mood (→ depression/anxiety), restless legs
- Prior treatment attempts (sleep hygiene changes? OTC meds? previous sleeping pills?)
- Functional impact: work, driving, relationships
Likely RFC examples:
- "Wants help with persistent insomnia affecting work performance"
- "Concerned the sleep problem indicates a serious underlying disease"
- "Wants sleeping pills"
- "Spouse complained about snoring and witnessed apnoea"
How to phrase: Choose the answer that best reflects why today – link the symptom to the patient's concern or functional impact, e.g., "Persistent insomnia for 3 months causing daytime fatigue and affecting work, wants treatment."
| Likely Content | Exact Wording Example | |
|---|---|---|
| Ideas | "I think the stress from my job is making me unable to sleep" / "Maybe I need sleeping pills" | Patient thinks work stress is causing the insomnia |
| Concerns | "I'm worried I have a brain problem / serious disease" / "Worried I'll have an accident because I'm so tired" | Patient worries the insomnia indicates a serious underlying condition |
| Expectations | "I want sleeping pills" / "I want to know why I can't sleep" / "I want a referral to a specialist" | Patient expects medication or investigation for the insomnia |
Chronic insomnia disorder (most common in FM primary care)
- Minimum supporting evidence: sleep difficulty ≥ 3 months, ≥ 3 nights/week, with daytime functional impairment, despite adequate opportunity for sleep, not better explained by another sleep disorder or medical/psychiatric condition [1]
GC 165 high yield: Insomnia is the most common sleep complaint in primary care. Chronic insomnia = ≥ 3 months, ≥ 3 nights/week, with daytime impairment. [7]
| DDx | Key Discriminator |
|---|---|
| 1. Obstructive sleep apnoea | Snoring + witnessed apnoea + EDS + obesity; confirmed by polysomnography (AHI ≥ 5) [2][3] |
| 2. Major depressive disorder | Low mood + anhedonia ≥ 2 weeks; early-morning waking pattern [4] |
| 3. Generalised anxiety disorder | Excessive worry ≥ 6 months; predominantly initial insomnia + autonomic symptoms [4] |
| Domain | Problem |
|---|---|
| Biological | Chronic insomnia with daytime fatigue and impaired concentration |
| Psychological | Anxiety about sleep / vicious cycle of worry → poor sleep → more worry; or underlying depressive symptoms |
| Social / Functional | Impaired work performance / risk of accidents if driving drowsy / marital strain due to snoring or irritability |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Chronic insomnia disorder | No reliable physical sign in a brief FM station | N/A – diagnosis is clinical based on history and diagnostic criteria | Use history criteria (duration, frequency, daytime impact) as exam clue. May note tired appearance, dark eye circles (non-specific). |
| OSA | Large neck circumference (> 43 cm M / > 41 cm F), Mallampati score III–IV, crowded oropharynx [2][3] | Measure neck circumference; inspect oropharynx (tongue, tonsils, uvula) | Crowded upper airway predicts obstruction during sleep |
| Major depression | Psychomotor retardation, flat affect, poor eye contact | Observe during consultation; assess speech rate, facial expression | Objective signs of depressed mood support the diagnosis |
| GAD | Tremor, tachycardia, sweating, restlessness | Observe patient's demeanour; check pulse, inspect hands | Autonomic hyperarousal signs support anxiety disorder |
| Hyperthyroidism | Fine tremor, tachycardia, lid lag, goitre | Extend hands for tremor; check pulse; inspect thyroid and eyes | Thyroid signs differentiate endocrine masquerade |
Exam Tip: Physical Sign for Insomnia
If the most likely diagnosis is chronic insomnia disorder, state explicitly on the CRF that "no specific physical sign exists; diagnosis is clinical." Then offer the best available supporting observation (e.g., "Patient appears fatigued with dark periorbital circles"). This honesty scores better than inventing a sign.
Top Traps That Lose Marks
- Forgetting to screen for depression/suicidal ideation – insomnia is a red flag for depression; examiners expect you to ask about mood.
- Not asking about snoring/witnessed apnoea – missing OSA is a serious safety concern (driving, cardiovascular risk).
- Jumping straight to "I'll give you sleeping pills" – BZD and sleeping pills should not be used for long-term management [5]. Examiners expect sleep hygiene counselling and CBT-I as first-line.
- Not asking ICE – ICE is a dedicated CRF section worth marks. Don't leave it out.
- Confusing sleepiness with fatigue – sleepiness manifests during sedentary activities; fatigue during exertion [2]. This distinction changes your DDx.
- Not asking about occupation/driving – safety risk assessment is essential.
- Not quantifying – must establish frequency (nights/week) and duration (weeks/months) to apply diagnostic criteria.
Must-not-miss red flags → urgent referral:
- Suicidal ideation in context of depression + insomnia → urgent psychiatric referral
- Witnessed apnoeas + severe EDS in professional driver → urgent sleep study referral
- Insomnia with acute confusion/delirium features → consider organic cause, A&E referral
Shortest safe management / safety-net line:
- First-line for chronic insomnia: CBT-I (Cognitive Behavioural Therapy for Insomnia) + sleep hygiene education [7]
- Short-term hypnotics only if severe, with clear plan to taper [5]
- Safety net: "If you feel very low in mood or have thoughts of hurting yourself, please go to A&E or call the crisis hotline immediately."
High-yield from GC 024 (A Fatigued and Sleepy Patient): Differentiate sleepiness from fatigue. Assess with Epworth Sleepiness Scale. Consider OSA in obese patients with snoring and witnessed apnoeas. Polysomnography is gold standard for OSA diagnosis. [8]
High-yield from GC 165 (I can't fall asleep): Sleep hygiene is cornerstone of management. Chronic insomnia diagnosis requires ≥ 3 months, ≥ 3 nights/week. CBT-I is first-line. Pharmacotherapy (short-acting BZD receptor agonists) is second-line and short-term only. [7]
High-yield from GC 017 (Common mental health problems in primary care): Depression and anxiety are the most common psychiatric comorbidities presenting with insomnia in primary care. Always screen for mood when a patient presents with sleep disturbance. [4]
High Yield Summary
What to ASK: Type of insomnia (initiating/maintaining/early waking), duration & frequency, daytime impact, snoring & witnessed apnoea, mood (depression/anxiety + suicidal screen), restless legs, sleep hygiene, medications/substances, occupation & driving safety, stressors, ICE.
What to WRITE on CRF: CC = insomnia × duration; HPI = type + frequency + daytime impact + associated features; RFC = link symptom to patient's concern/impact; ICE = all three; Dx = chronic insomnia disorder (criteria: ≥ 3 mo, ≥ 3×/wk, daytime impairment); DDx = OSA, depression, GAD; Biopsychosocial = fatigue (bio) + worry/mood (psych) + work/driving impact (social); Physical sign = no specific sign for insomnia (state this), but check oropharynx/neck for OSA.
What NOT to MISS: Depression & suicidal ideation screen, OSA screen (snoring + apnoea + EDS), driving/machinery safety, substance use, and do NOT promise long-term sleeping pills.
Active Recall - Family Medicine Clinical Test
[1] Senior notes: Ryan Ho Psychiatry.pdf (Section on Insomnia, p.223, p.229) [2] Senior notes: Ryan Ho Respiratory.pdf (Section on Sleep-Associated Disorders, p.155–159) [3] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (Polysomnography, p.298–300) [4] Lecture slides: GC 017. Common mental health problems in primary care.pdf [5] AOS material: AOS - Psych.md (Sleeping pills and BZD not for long-term management) [6] Lecture slides: GC 114. Climacteric symptoms menopause and related illness; amenorrhoea.pdf [7] Lecture slides: GC 165. I can't fall asleep Sleep physiology and Sleep disorders.pdf [8] Lecture slides: GC 024. A Fatigued and Sleepy Patient.pdf
Neck Pain / Stiffness
Neck pain or stiffness is discomfort or restricted range of motion in the cervical spine region, commonly caused by muscular strain, degenerative disc disease, or cervical spondylosis, but requiring urgent evaluation when associated with meningeal signs or neurological deficits.
Shoulder Pain
Shoulder pain is a common musculoskeletal complaint arising from disorders of the rotator cuff, glenohumeral or acromioclavicular joints, bursa, or referred sources such as cervical spine or visceral pathology.