Worked example · Insomnia in a 68-year-old man
Watch a 2 become a 3
One case, six steps. At each one you get the situation and a prompt. Write your own answer, then reveal the pair: the response that scores a 2 beside the response that scores a 3.
Write before you reveal
The two model answers usually contain the same medical knowledge — the gap between them is entirely in what got written down. You will only feel that if your own words are on the screen first. Reading a model answer feels like learning and mostly is not. Nothing you type is saved or sent anywhere.
Problem representation
Harold Baptiste, 68, comes to your clinic because he "can't sleep." For six weeks he has woken at 3 am and been unable to get back to sleep. He has lost 20 pounds without trying, has no appetite, and has stopped attending the woodworking club he ran for eleven years. He says he feels "like a burden to everybody." His wife died fourteen months ago. He has hypertension and benign prostatic hyperplasia, takes amlodipine and tamsulosin, and smoked a pack a day for forty years before quitting at 58. BP 138/82, HR 72, RR 14, SpO₂ 97%, temp 98.2°F.
Write your problem representation before you list a single diagnosis.
Initial differential
You have the stem and nothing else. No history beyond what he volunteered, no exam, no labs.
List your initial differential. Aim for breadth, with every entry defensible.
Directed history
You have twelve minutes with him. He is quiet and will answer what you ask, but volunteers little.
What do you ask? Tie each question to something on your own list.
Ranked differential, with evidence
History adds: sadness is constant rather than in waves, and nothing lifts it. Mornings are worst. He has lost interest in everything, not only in things that remind him of his wife. He denies cough, hemoptysis, bowel change, and pain. No cold intolerance. He drinks two beers a week, unchanged. His daughter says his memory is fine and he manages his own finances. He has thought "everyone would be better off," has no plan, and there is no firearm in the house. Exam is unremarkable; he is thin, psychomotorically slowed, and tearful.
Rank your differential. Attach the evidence to each entry.
Orders
You can order what you like.
Place your orders. Name the hypothesis each group tests.
Formulation and plan
Chest radiograph is clear. TSH 2.2, B12 410, CBC and CMP unremarkable. PHQ-9 is 21. C-SSRS: passive ideation, no plan, no intent, no access to means.
State your formulation and your plan.
What carried across all six steps
- Every model answer ends on the thing that discriminates, not on the conclusion.
- Each diagnosis carries two findings for it and one against it — never a bare name.
- Each question is owed to a specific entry on the list, and the can't-miss entries get asked about even when the answer is expected to be no.
- Orders are grouped and each group is labelled with the hypothesis it tests. Four extra tests cost more than they add.
- The plan says out loud which can't-miss was considered and set aside, and names the tripwire that would reopen it.
- Nothing is stated as certain that the workup has not yet earned.
This case was written for IvyMed. It is not reproduced from any commercial question bank or case simulator.