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| * neuroq2 |
| | #531308 |
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A 38-year-old man is seen in follow-up for clavicular fracture sustained in a motor vehicle accident 6 weeks ago, requesting clearance to return to work. He had been driving alone in daylight when his car left the road at a curve and struck a tree. He does not think he lost consciousness or struck his head, but he does not remember leaving the road. He recalls no prodrome and remembers clearly the sound of crunching metal from the impact. The patient does not smoke, drink, or use other drugs. He is obese and was diagnosed with type 2 diabetes mellitus and hypertension 3 years ago and takes metformin and enalapril as his only medications. He has never had hypoglycemia and has no history of cardiac or neurologic diseases including seizures.
On evaluation by medics at the site of the accident, his pulse rate was 90/min and regular, blood pressure was 150/1 00 mm Hg, and blood glucose was 180 mg/dL. He was alert, oriented, and complained only of anterior shoulder pain at the site of the fracture. He was evaluated in the emergency department and has been treated conservatively with a shoulder sling, pain medication, and physical therapy. He feels ready to return to work.
On specific questioning, he reports three near-miss car accidents in the past 2 years; in none of these cases is he quite sure what happened.
What is the next information you would obtain to look for an underlying explanation for his driving history?
A. Neuropsychiatric testing
B. Polysomnography
C. 3-day blood glucose monitoring
D. Electroencephalography |
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| * Re:neuroq2 |
| #2189876 |
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Recognize inadequate sleep (sleep deprivation and undiagnosed sleep disorders) as a major cause of
accidents and repeat near-misses.
Critique
Taking a sleep history is the best next step, as sleep deprivation and undiagnosed, untreated sleep disorders (particularly obstructive sleep apnea) are common, underrecognized causes of impaired driving, and because this patients history does not clearly suggest another cause. The risk of motor vehicle accidents is significantly increased (at least 5-fold) in each of these situations: (1) sleepy driver, (2) driver with untreated obstructive sleep apnea and prior near-misses, and (3) during predawn hours. The trucking industry and sleep specialists are most aware of this problem; awareness among the public and among most physicians is lower. Treatment of obstructive sleep apnea with nocturnal CPAP reduces the risk of motor vehicle accidents and near-misses to that of the general population. After obtaining a sleep history, vision testing and drug testing would both be reasonable to perform. This patients history of momentary reduced awareness and driving performance, without prodrome or postictal state, make seizure disorder or hemodynamically significant arrhythmia unlikely as an explanation for his recurrent driving impairment |
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