First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 29. 20-Year-Old Woman with Sleeping Problems


Opening Scenario

Gwen Potter, a 20-year-old female, comes to the clinic complaining of sleeping problems.

Vital Signs

BP: 120/80 mm Hg Temp: 98.6°F (37°C)

RR: 18/minute HR: 102/minute

Examinee Tasks

1. Take a focused history.

2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).

3. Explain your clinical impression and workup plan to the patient.

4. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

Patient is a 20 yo F of average height and weight.

Notes for the SP

 Look anxious and irritable.

 Pretend that you are worried about performing well in college.

 Exhibit a fine tremor on outstretched fingertips and brisk reflexes.

Challenging Questions to Ask

“Will I ever be able to sleep well again, doctor?”

Sample Examinee Response

“First we need to run some tests to rule out underlying medical problems. In the meantime, I recommend some lifestyle changes. If you drink coffee, I strongly recommend that you cut down on your caffeine intake. You could also benefit from exercising, preferably during the day and not right before bedtime. Finally, you should get into the habit of going to bed early—for example, at 10 p.m. each night. It would help if you went to sleep around the same time each night and woke up around the same time each morning. I would also encourage you to abstain from drinking alcohol several hours before bedtime.”

Examinee Checklist

Building the Doctor-Patient Relationship Entrance

 Examinee knocked on the door before entering.

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

Connecting with the Patient

□ Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.


 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans.

□ Follow-up tests.

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Ms. Potter, on the basis of your history and my examination, I think there are a few factors that might be contributing to your sleeping problems. The first is the anxiety and stress you’ve been experiencing over performing well in college. Although this is perfectly understandable, you may not be able to perform at your best if you don’t get a good night’s sleep. On the other hand, your problems could stem from your caffeine use, which I urge you to reduce or stop completely. Another possibility has to do with your thyroid function. Sometimes hyperactivity of the thyroid gland can cause some of the symptoms you describe, and the only way to rule this out is through a blood test. In light of your history of snoring, we may need to do a sleep study in the future to rule out sleep apnea. At this point, I encourage you to proceed with the lifestyle changes I have recommended, and I will see you for follow-up to find out how you are doing. Do you have any questions or concerns?


HPI: 20 yo F college student c/o Inability to sleep. She has difficulty falling asleep until 2 a.m. and also has difficulty staying asleep. She used to get 8 hours of sleep, but for the past month she has been getting a total of only 4 hours per night. She has difficulty getting up after hearing the alarm and feels tired while at school. She notes inability to concentrate during classes and while driving. The patient appears to be stressed about her coursework and about her performance at school. She has also been snoring for the past few months and has had palpitations, especially after drinking caffeine. She has a history of drinking 4-5 cups of coffee per day. She has lost weight (6 lbs in 1 month) and has sweaty palms. There is an increase in the frequency of her bowel movements. She lives with her boyfriend, and they use condoms and OCPs for contraception. There is no history of sexual abuse, recent infection, or recent tragic events in her life.

ROS: Negative except as above.

Allergies: NKDA.

Medications: Multivitamins, OCPs.

PMH: None.

PSH: Tonsillectomy at age 12.

SH: No smoking, 1-2 beers/week, no illicit drugs.

FH: Not significant.

Physical Examination

Patient appears anxious and restless.

VS: HR 102/minute.

Chest: Clear breath sounds bilaterally.

Heart: Tachycardic; normal S1/S2; no murmurs, rubs, or gallops.

Abdomen: Soft, nontender, nondistended,BS, no guarding, no hepatosplenomegaly Skin: Normal, no rashes, palms moist.

Neuro: Brisk reflexes.

Differential Diagnosis


Patient Note Differential Diagnoses

 Anxiety: Fatigue and sleep disturbances are common in anxiety states. The clinical manifestations of anxiety can be both psychological (eg, tension, fears, difficulty concentrating) and somatic (eg, tachycardia, sweating, hyperventilation, palpitations, tremor). This patient describes irritability, trouble concentrating, and difficulty sleeping for more than six months, which supports a diagnosis of generalized anxiety disorder. The source of her anxiety is likely her desire to excel in college. Although not required for an official diagnosis of generalized anxiety disorder, somatic manifestations of anxiety are many and include tachycardia, sweating, hyperventilation, palpitations, and tremor.

 Caffeine-induced insomnia: The most common pharmacologic cause of insomnia, caffeine use produces increased latency to sleep onset, more frequent arousals during sleep, and a reduction in total sleep time several hours after ingestion. Even small amounts of caffeine can significantly disturb sleep in some patients. This patient’s high intake of coffee makes caffeine-induced insomnia a possible diagnosis.

 Hyperthyroidism: Clinical hyperthyroidism is associated with anxiety, tremor, palpitations, sweating, frequent bowel movements, fatigue, menstrual irregularities, unintentional weight loss, and heat intolerance. The patient presented in this case has anxiety, palpitations, sweating, increased bowel movements, fatigue, and weight loss, suggesting the need to rule out hyperthyroidism.

Additional Differential Diagnoses

 Insomnia due to depression: Several mood disorders are associated with insomnia. Depression can be associated with sleep onset insomnia, sleep maintenance insomnia, or early-morning wakefulness. Hypersomnia occurs in some depressed patients, especially adolescents and those with either bipolar or seasonal (fall/winter) depression.

 Insomnia secondary to adjustment disorder: Any significant life event, such as a change of occupation, loss of a loved one, illness, or examinations, can be a significant stressful event in people’s lives. Behavioral or mood changes associated with adjustment disorder typically start within three months of the stressful event, end six months after the stressor, and cause significant impairment in one’s life. Increased sleep latency, frequent awakenings from sleep, and early-morning awakening can all result. Recovery is rapid, usually occurring within a few weeks.

 Illicit drug use: Drugs such as cocaine and amphetamine increase sympathetic activity and can thus cause insomnia.

 Obstructive sleep apnea (OSA): More than 50% of patients evaluated for OSA complain of symptoms of insomnia, including difficulty in initiating and maintaining sleep and early-morning awakening. OSA has a higher association with obesity and large tonsils. However, given that this patient has had a tonsillectomy, it is unlikely that enlarged tonsils secondary to OSA are the cause of her disorder.

Diagnostic Workup

 TSH, FT3, FT4: The patient gives a history of weight loss, increased frequency of bowel movements, palpitations, and sweaty palms, all of which suggest hyperthyroidism. An elevated FT4 with suppressed TSH is diagnostic.

 Urine toxicology: Although this patient denies illicit drug use, a toxicology screen will help rule out the use of CNS stimulants that can cause insomnia (eg, cocaine, amphetamine).

 CBC: Can help detect anemia, hidden infection, or malignancy, all of which can cause the fatigue and weight loss seen in this patient.

 Polysomnography: A diagnostic test for OSA syndrome that can also help assess the severity of the disease as well as any comorbidities with which it might be associated.

 ECG: Nonspecific changes can be seen with hyperthyroidism and anxiety disorders.

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