Case 16: Trouble sleeping

Opening scenario

Madelyn Connors, a 32-year-old female; , comes to the doctor’s office because of trouble sleeping.

Vital signs

• Temperature: 97.7°F (36.5°C)
• Blood pressure: 135/70 mm Hg
• Heart rate: 90/min
• Respirations: 17/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Act stressed out and anxious. Talk fast.
• You are not aware of the meanings of medical terms (e.g., ECG) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Ask “Can you write me a letter so I do not have to go into work?”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• I have terrible trouble sleeping.
• Onset
• I do not think I have had a good night's sleep for about a year now.
• Constant/intermittent
• Every night.
• Precipitating events
• It began around the time I started my current job.
• Progression
• It is getting worse; I hardly sleep nowadays.
• Previous episodes
• I had a little bit of insomnia while I was doing my undergraduate degree, but only around final examination time.
• Alleviating factors
• Nothing really.
• Aggravating factors
• I think it gets worse with stress, which is basically constant for me right now.
• Associated symptoms
• I also have trouble concentrating at work lately. So now I have to stay late to get all my work done.

Review of systems specific to sleep disturbances

• Headache
• No.
• Fatigue
• Of course, I am constantly tired.
• Racing of the heart
• Yes. Especially if I am lying in bed and thinking about all the work I have not gotten around to or how I could have prepared more for a case, my heart really starts racing.
• Chest pain
• When my heart is racing, my chest also sometimes feels really tight. It is not really pain though.
• Shortness of breath
• No.
• Bowel problems
• No, not really. But I have noticed that I have had to go to the toilet more often; the past few months, like 4 or 5 times a day but usually with small amounts.
• Appetite
• I try to eat whenever I can fit it in. I feel that I get hungry throughout the day because my stomach is growling, but I do not usually have much of an appetite for anything.
• Weight changes
• I do not typically weigh myself, but I probably lost some weight over the past year. I used to wear a size 8 and now I am a 4.
• Dizziness
• Only if work gets too busy and I forget to eat.
• Difficulty falling sleep
• Yes. I usually lay in bed for hours before I can sleep.
• Waking up frequently in the night
• No. Once I finally fall asleep, I usually feel okay.
• Early waking
• Yes. I usually wake up before my alarm goes off.
• Feeling fatigued after awakening
• Yes. I do not ever feel rested when I wake up.
• Bedtime routine (sleep hygiene)
• I usually come home late, around 11 PM, then I eat a late dinner, take a shower and try to go to bed because I have to get back up at 6 AM.
  • Alcohol before going to bed
  • No.
  • Caffeinated drinks
  • Yes. I drink about 6–7 cups of coffee throughout the day and into the evening. If I still have trouble staying awake in the evening, I sometimes drink an energy drink to make it through those last few hours at work.
  • Large meals before bedtime
  • No. I typically have something light like a salad for dinner.
  • Exercise before going to bed
  • I do not have time to exercise at all.
  • TV in the bedroom
  • Yes. I usually keep it on because it distracts me from my own thoughts.
• Mood
• I feel like I am always anxious and worried about my future. But I do not feel sad or depressed.
  • Duration of anxiety
  • I have always been a person who worries a lot, but it really got worse with my new job.
• Excessive sweating/heat intolerance
• No.
• Tremor
• No.

Past medical history, family history, and social history

• Past medical history
• None.
• Allergies
• None.
• Medications
• No.
• Hospitalizations
• Never.
• Past surgical history
• None.
• Family history
• My mother has something wrong with her thyroid gland. I do not remember the term for it though, or what the problem is.
• Work
• I am a lawyer. I just started in a big firm about a year ago. It is incredibly competitive, and I am so afraid to make any mistakes. I do not know how much longer I can take the pressure, but I also cannot quit.
• Home
• I live by myself.
• Alcohol
• Rarely. I am always afraid that I will not be able to get up early the next morning.
• Recreational drugs
• Never.
• Tobacco
• Never.

• Washed hands
• Used respectful draping
• Head, eyes, ears, nose, and throat examination
  • Examination of the pupils
  • Inspection of the conjunctiva
• Neck examination
  • Examination of the thyroid gland
• Cardiovascular examination
  • Inspection of the chest
  • Palpation of the radial pulse
  • Auscultation of the heart
• Extremities
  • Inspection of the hands
• Neurologic examination
  • Focused examination of deep tendon reflexes

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on sleep hygiene.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: ”Ms. Connors, I understand that you are under a lot of pressure at work and I agree that this is likely affecting your sleep. While I can write you a note so that you do not have to go back into work today, I believe that we should find a more long-term solution for your sleep problems. I would like to evaluate your sleep disturbance a little further and find out what is causing it so that we can treat you appropriately. In the meantime, there are a number of things that you can do to improve your sleep hygiene.”

Patient note

Differential diagnoses

1. Generalized anxiety disorder (GAD): This disorder involves prolonged and excessive anxiety that is either nonspecific or revolves around certain themes, such as work, as in this patient. Since beginning her new job, she has experienced psychological distress in the form of anxiety about the future (rather than the past, as in depression), sleep disturbances, difficulty concentrating, and fatigue – all symptoms of GAD. Her decreased appetite and weight loss are likely due to stress, and her palpitations and episodes of chest tightness could be due to panic attacks, which can occur in GAD. The patient's statement that she has “always been a person who worries a lot” indicates that she is predisposed to generalized anxiety disorder. Additionally, females are twice as likely to experience GAD compared to males.
2. Insomnia disorder: Insomnia disorder is subdivided into several types, depending on what point in the night sleep disturbances occur. This patient would appear to have initial or sleep-onset insomnia and late or sleep-offset insomnia, as well as nonrestorative sleep. She also has several poor sleep hygiene habits (high caffeine intake, TV in the evenings, and lack of exercise). However, the DSM-5 definition of insomnia stipulates that it is a diagnosis of exclusion so that GAD and other psychiatric conditions would have to be excluded before insomnia disorder could be confirmed. In any case, good sleep hygiene will probably benefit this patient.
3. Hyperthyroidism: This patient has a family history of thyroid disease as well as some symptoms of hyperthyroidism, including weight loss, hyperdefecation, fatigue, palpitations, neuropsychiatric symptoms (sleep disturbances, difficulty concentrating, anxiety), and elevated blood pressure with wide pulse pressure. However, her weight loss is likely due to her decreased appetite under stress, whereas in hyperthyroidism weight loss would occur despite increased appetite. In addition, she does not have any other features of hyperthyroidism, which might include excessive sweating, tremor, and brisk DTRs. Nevertheless, her blood pressure merits a closer look in the form of 24-hour monitoring.

Diagnostic studies

• Sleep diary: Patients are instructed to note how many hours they sleep, how often and when they awake, and how well-rested they feel when waking up. This process helps to determine the extent of insomnia.
• ECG: The patient complains of occasional chest tightness, which means that myocardial ischemia should be ruled out.
• Urine toxicology: to rule out stimulant use.
• Long-term measurement of blood pressure (24 hours): Because this patient presents with elevated blood pressure (AHA/ACC guidelines 2017), blood pressure should be measured again.
• TSH, FT₃, FT₄: Normal TSH levels rule out overt hyperthyroidism and hypothyroidism.
• CBC: to assess for anemia as a cause of fatigue.

Other differential diagnoses to consider

• Substance abuse
• Obstructive sleep apnea
• Depression
• See also anxiety disorders.