1. SCENARIO (slide 2) CHOICE A (slide 3) CHOICE B (slide ?)
Select a patient
When all patients have been chosen, click Follow-up (or something that would happen at the end)
SLIDE ?
FOLLOWUP
CHOICE A (slide 3)
PATIENT: Bob
CHOICE B (slide ?)
PATIENT: Sally
CHOICE C (slide ?)
MISSION: Ophelia
CHOICE D (slide ?)
MISSION: James
DIAGNOSIS (?)
DIAGNOSIS (?)
DIAGNOSIS (?)
DIAGNOSIS (?)
TREAMENT (?)
TREAMENT (?)
TREAMENT (?)
TREAMENT(?)
CHOICE A (?)
Worst
CHOICE A (?)
Worst
CHOICE A (?)
Worst
CHOICE A (?)
Worst
CHOICE B (?) Ok
CHOICE B (?) Ok
CHOICE B (?) Ok
CHOICE B (?) Ok
CHOICE C (?)
Good
CHOICE C (?)
Good
CHOICE C (?)
Good
CHOICE C (?)
Good
CHOICE C (?)
Best
CHOICE C (?)
Best
CHOICE C (?)
Best
CHOICE C (?)
Best

2. INSERT SCENARIO AND INSTRUCTIONS:
Example instructions: “Assume you are a ________. In this exercise, you will be presented with four different patients. Use the given information to determine what is the best form of treatment.”
PATIENT 1: BOB
Description/Diagnosis:
Overall Health
Bob is a 17-year old male that is overweight. His parents bring him in to the physician because of excessive daytime sleepiness and on going teacher complaints of inattentiveness that includes daydreaming. The school nurse has sent notes home asking if Bob has a seizure disorder. He has always been very clumsy and mom has asked about seizures before, and the pediatrician says he does not have seizures.
Sleep
When he was younger, he would have vivid scary dreams, where he would say he couldn’t move, so it made them more scary.
Choice A: Worst
Ignore the situation, address inattentiveness with medications that address ADHD. (Medication for ADHD)
Follow up: For the last month Bob has done exactly what the doctors have recommended, nothing. The result has been more calls to his parents for disruptive behavior in the classroom, a scheduled meeting with the school counselor and another doctor’s appointment to increase his ADHD medications.
Feedback: This choice does not address the sleep disorder, it dismisses the concerns of the family and the school.
Choice B: OK
Medication to treat symptoms (Medication for daytime sleepiness)
Follow up: Bob has had an increase in his ADHD medications, and he is responsible to take them when he should. To the dismay of those around him, his lack of attention continues and he still falls asleep in class.
Feedback: Medication to treat symptoms as opposed to having medications that address the symptoms with the information that helps the family understand what is going on with Bob. This is just a Band-Aid. (Drugs without education/support)
Choice C: Good
Patient and family education.
Follow up: Bob and his family understand what is happening, and that for the most part, Bob doesn’t have any real control over it. At his follow up doctors appointment, Bob is able to explain his condition to the new resident, but when asked what he is doing to treat it, Bob doesn’t have any answers.
Feedback: By itself this only addresses a small part of what is going on for Bob. This choice will allow for the discussion of behavioral changes and the importance of sleep hygiene, but it is only a discussion, not an action plan.
Choice D: Best
Combination of sleep hygiene, behavioral changes and medications.
Follow up: Over the last 2 months it has been noted by the teachers that Bob is no longer a disruption in class, he is following directions better and his grades have improved. He has not been to the principals office since he began all of his treatments.
Feedback: Each of these changes will allow Bob to return to normal functioning in school, home and in social situations. Bob has narcolepsy and this will distress all of his issues.

3. INSERT SCENARIO AND INSTRUCTIONS:
Example instructions: “Assume you are a ________. In this exercise, you will be presented with four different patients. Use the given information to determine what is the best form of treatment.”
PATIENT 2: SALLY
Description/Diagnosis:
Overall Health
Sally is a 61-year-old woman who is a busy physician and has had type 2 diabetes for 11 years. She suffers from gastroesophageal reflux disease daily and has moderate depression. For 11 years, she has maintained a weight of 210–220 lb (BMI of 31 kg/m2), and she does not have hypertension or hypercholesterolemia. Sally has no other known diabetes complications. She uses a low-carbohydrate meal plan and a bicycle exercise program.
Sleep
However, she snores and reports being excessively sleepy all the time. The patient denies polyuria or nocturia. Her husband does not complain about her nighttime snoring, but he describes himself as a heavy sleeper.
However, fellow physicians who travel with Sally on medical mission trips joke and complain about her snoring and gasping. She did not share this information with her diabetes care team. Sally is excessively sleepy, yet she sleeps ∼ 8 hours nightly. Colleagues and family who sleep in adjacent rooms have told her that she snores and gasps throughout the night.
Choice A: Worst
Continue to observe Sally and have her complete a sleep diary.
Follow up: During the last few months of observation, Sally has had multiple cardiac issues. An increase in angina, a trip to the ED because it was thought she was having a heart attack.
Feedback: Ignoring symptoms of OSA because of the potential co-morbidities that can occur.
Choice B: OK
Behavioral modifications to include wedges for
sleeping, and weight management.
Follow up: Since her last appointment 3 months ago, Sally’s BMI is down to 29 kg/m2, her blood sugars are more under control, she states she feels better, not as worn down.
Feedback: This only begins to address the issues that Sally is having. Because her BMI is high, she may need other interventions while trying to manage her weight.
Choice C: Good
After attempting behavior modifications, using dental devices that help to pull the jaw forward in an attempt to relieve the obstruction of the tongue.
Follow up: It took Sally a couple of months to get into the dentist, during that time she began her behavior modifications and began losing weight. Once the impressions came back and she was able to use the dental device, her sleep has subjectively improved and she feels less depressed.
Feedback: Once weight management has been done, or as it is occurring, attempting other ways to alleviate obstructions may also help. The use of dental devices keeps the tongue from falling and creating more of an obstruction.
Choice D: Best
A PSG that includes CPAP intervention and titration. Once the appropriate level of CPAP has been determined, the continuing use at home with all of the proper patient/family education to insure the best patient adherence.
Follow up: Since receiving her CPAP/BiPAP unit, Sally has been extremely adherent to her therapy, and on a recent Doctor’s visit it was noted that she is much more clear headed at work, seems to be well rested, and she continues to drop her weight.
Feedback: The use of a CPAP/BiPAP to relieve an obstruction is the Gold Standard for OSA, which is what Sally is dealing with. The challenge is patient adherence to therapy.

4. INSERT SCENARIO AND INSTRUCTIONS:
Example instructions: “Assume you are a ________. In this exercise, you will be presented with four different patients. Use the given information to determine what is the best form of treatment.”
PATIENT 3: OPHELIA
Description/Diagnosis:
Overall Health
At birth it was discovered that Ophelia has Pierre Robin Syndrome and has a significantly small jaw. It was decided that she would go home with specific instructions on how to place her to sleep. She is coming in today because she is no longer thriving at home and her parents have many questions as to what are their options and how those options will impact their lives and Ophelia’s. Ophelia is now 2 months old.
Sleep
Ophelia has been sleeping loudly, not restfully according to her parents. This is also evident in the dark circles under her parent’s eyes. The lack of sleep is effecting her growth, as she has now fallen off the growth curve.
Choice A: Worst
Behavior modification – modify the child’s behavior.
Follow up: At 2 months of age, there is no behavior modification to be done.
Feedback: This is an impossible choice for a 2 month old. How many behaviors can a 2 month old have? This is not a choice primarily based on her age.The patient is not obese, already sleeping on their side, as Ophelia’s parents are using wedges, and at the age of 2 months, there are not many behavior modifications that can be done.
Choice B: OK
Dental devices, well, how many 2 month olds have all of their teeth and are no longer going to have bone growth in their faces? The purpose of dental devices is to pull the jaw forward or to hold the tongue forward, as the jaw grows, there will be a need to refit the device. This is also not a cost effective treatment because of the growing jaw.
Follow up: Ophelia’s parents found a dentist that specializes in pediatric care to see if there was a dental device that she could use. The dentist told them that this was not an option for Ophelia because of her age.
Feedback: at 2 months of age, there is too much growing that has to occur, and there would be an increase in expense for her parents that is unnecessary at this time.
Choice C: Good
CPAP/BiPAP, as this the Gold Standard for OSA, it is the last of the non-invasive techniques to remove an obstruction causing sleep apnea.
Follow up: Ophelia’s pediatrician wanted to try this modality, but ran into issues with an appropriate interface device. When one was tried, Ophelia was very irritable, her parents didn’t sleep at all and her OSA continued.
Feedback: once CPAP/BiPAP has been tried, with appropriate patient/family adherence, and the apniec episodes are not controlled, then this option is no longer the right choice. For Ophelia this is not the best option because of the lack of appropriate interfaces for a 2 month old, and the significance of her obstruction.
Choice D: Best
Surgery– specifically a tracheotomy.
Follow up: Ophelia received her trach 3 months ago, she is now 5 months old and thriving. She has been scheduled to have her first jaw surgery and will need to have more after that. The ENT physician will decide when her trach can come out, it was already decided that she will not need this for the rest of her life.
Feedback: this is the only definitive way to alleviate the obstruction and permanently fix the OSA that Ophelia has. Once the surgical correction of her jaw is complete, the tracheostomy can be removed as it does not have to be a permanent need.

5. INSERT SCENARIO AND INSTRUCTIONS:
Example instructions: “Assume you are a ________. In this exercise, you will be presented with four different patients. Use the given information to determine what is the best form of treatment.”
PATIENT 4: JAMES
Description/Diagnosis:
Overall Health
James, a 250 lb, 45-year old, has been a nightshift and swing shift worker for as long as he can remember. His schedule rotates every other month, so his sleep is very disrupted. In order to stay awake while he’s on night shift, he turns to his 60 pack year smoking habit and coffee. At his last physical, more than a year ago, he was told he had hypertension and was placed on medication. He was also told that his BMI was 32 kg/m2 and that he must watch his diet and loose some weight. He has a history of gastric reflux disease, which he is also on medication for. He recently was remarried and he and his wife are attempting to have children. This has been to no avail, they are blaming the late and long hours he works.
Sleep
James has been irritable at home, according to his wife, he has trouble rotating from swing shift to night shift sleeping. He complains of having insomnia and needing medication to fall asleep, but then wakes sleepy and unable to concentrate.
Choice A: Worst
Allow James to continue what he is doing.
Follow up: Since James’ refusal for medical intervention, he has been in 2 accidents, one at work and one motor vehicle. In the later, the driver of the other car was taken to the hospital with minor injuries.
Feedback: Not addressing the sleep disorder can be extremely detrimental to the not only James’ health, but for those around him as well. Remember, he has to drive home. The issues he and his wife are having with infertility may be directly related to his sleep disorder.
Choice B: OK
The use of light therapy should be the first line choice for these patients. Then the use of medications, specifically hypnotics, stimulants and melatonin.
Follow up: Over the last 6 months, James has been inconsistent taking his medications, and does not believe that the light therapy is working, so he has stopped using both, without notifying is physician. Needless to say, he is not sleeping any better.
Feedback: These treatments do not address the underlying issue of the circadian rhythm. These are considered a Band-Aid. Melatonin supplements taken before bedtime can help promote sleepiness. Melatonin supplements are not prescription medications, and are not regulated by the Food and Drug Administration
Choice C: Good
Maintain the nocturnal schedule all of the time.
Follow up: Initially James thought this would be a great thing! Keep on the night shift schedule! This was the case, until he had to go to the bank, his doctor’s appointments, kids’ parent teacher conferences, etc. After a couple of weeks, James decided that this was just not practical for his family life and went back to rotating his schedule, and being sleepy.
Feedback: This is not always practical, life does not run 24/7/365 and there are “regular” schedules for things like the bank.
Choice D: Best
Commitment to a work schedule. Preferably a day shift schedule, based on James’ age, this would be a healthier choice for him. He is at risk for many more co-morbidities: cardiovascular and diabetes.
Follow up: James had a long talk with his boss, and it was decided that James was too valuable of an employee and there was a day shift position open, so he was moved to dayshift. This change improved everything for James, form his relationships at home and at work. He is rested, awake and can function better at everything he does now.
Feedback: A younger individual may be better suited for this schedule, and it would be better for James to have a consistent schedule. James has Shift Work Disorder, a type of Circadian Rhythm Disorder.