Anxiety - case study PDF

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Date: 7.1.21 Primary Case Author: Rachel Older Name of Case: Anxiety Name of education and or assessment activity: M3 Standardized Patient Psychiatry Clerkship Case Patient Name: Evan/Eva Fowler Chief Complaint: “3 months ago, I started having these episodes where I had trouble breathing, tunnel vision, and my heart beating really fast. I knew something bad was going to happen but couldn’t break out of it. Then about 3 days ago, this happened to me again and I thought I was having a heart attack. I felt like I was going to die!” Most likely Diagnosis and Differential with rationale from history and/or physical exam: Anxiety Disorder Domains: √Professionalism √Communication and Interpersonal skills √Medical History □ Physical exam √Shared Decision Making √Patient Education √Clinical Reasoning √Documentation □ Handoff □ Presentation □ Other: Type and level of learner: 3rd year medical student Case Objectives: By the end of this activity, the learner will be able to: 1. 2. 3. 4. 5. 6.

Setting Patient Profile

Obtain a thorough history and focusing ability to build rapport with the simulated patient Recognize symptoms of the disease Apply knowledge of clinical features in the evaluation of a differential diagnosis Recommend appropriate work up to rule out other causes of the psychiatric disorder Suggest a treatment plan including medications and therapy modalities Attempt to develop a patient-centered biopsychosocial formulation

Outpatient Clinic About 3 months ago, you started having these episodes of shortness of breath, tunnel vision, and your heart-beating really fast. You also felt an impending sense of doom and couldn’t control these feelings. 3 days ago, it was so bad you thought you were dying. Your wife/husband took you to the ED. By the time you got there you were also sweating and nauseous. You thought you were having a heart attack. The doctor conducted a physical, ran an EKG, and did bloodwork, but said everything was ok.

The ER doctor recommend you go and see a psychiatrist. You are anxious, upset, and frustrated Stressors:  Stressed about work. You are the lead on a major account.  You are working closely with a colleague you don’t get along with.  Your daughters are in dance class and swim lessons. By the time you get home, eat dinner, and help with homework, it’s time to get the girls to bed.  If you don’t meet your deadlines at work, you could lose your position as lead accountant for this major firm.  Your 15-year anniversary is coming up. Your spouse does so much to support you, you are afraid of letting him/her down. You have no idea what to get him/her.  There’s an opening at a competing accounting firm for a higher-level position. Your spouse wants you to go for it, but you like the company you are with.  Getting that position would mean more income for the family, and your daughter, Kylee, is going to need braces. It would also mean you could take the family vacation to Disney Land you keep talking about, but never do.  You feel Kylee and Maya (daughters) should have been to Disney Land by now.  You feel that your spouse is supportive but must be getting sick and tired of these episodes. If you can’t pull it together, there’s no chance of considering a new job. You are worried you may have an episode during the interview.  It feels like you’re juggling right now and one or all of the balls is going to fall. Age Range Religious/spiritual background Sex Sexual Orientation Gender Expression Race/ethnicity Physical description Physical limitations Patient appearance Moulage + location Affect

Family Group Education Level of Health literacy Employment

Home/homeless

35-45 You are agnostic with no religious classification. Male/female Heterosexual/lesbian/gay/bisexual/pansexual Man/woman/gender queer Any Patient should appear between 35-45 years of age; physical weight, height, and gender does not impact the case. None Patient is dressed in street clothes/casual dress none You are sitting on the edge of your seat with the appearance of stress. You are tapping your foot and your eyes are darting around the room. Your speech is faster than normal. You live with Lance/Lucy (age 42), your spouse of 14 years and your two daughters, Kylee (10) and Maya (8). High academic performance throughout high school/college Master’s degree in accounting proficient Accountant for a local firm for the last 10 years. Worked as a bookkeeper than accountant after high school in at previous position with a different firm. You are stressed about work. You are the lead on a major account and working closely with a colleague you don’t get along with. If you don’t meet your deadlines at work, you feel could lose your position as lead accountant for this major firm. You live in a two-story home in a suburb; you own it but are still paying off the

Financial situation Insurance Status Habits Activities Typical day

CASE INFORMATION Chief Concern

Other concerns THE PATIENT STORY

HISTORY OF PRESENT ILLNESS

mortgage. You have enough money for food, shelter, and security. Insured through work - PPO You drink a cup of caffeinated coffee each morning and have an occasional glass of wine a few times a year. You work and take your daughters to dance and swim lessons. You do not have time for anything else. Go to work after you get the kids ready in the morning. When you get home, you take your daughters to dance or swim lessons. By the time you get home, eat dinner, and help with homework, it’s time to get the girls to bed. “3 months ago, I started having these episodes where I had trouble breathing, tunnel vision, and my heart beating really fast. I knew something bad was going to happen but couldn’t break out of it. Then about 3 days ago, this happened to me again and I thought I was having a heart attack. I felt like I was going to die!” Work and family – no other medical concerns “I’m having some difficulty sleeping. I’m afraid of getting another attack and can’t stop worrying. I don’t see how a psychiatrist will help. I’m not suicidal – these are physical symptoms.” “The ER doctor asked me to take deep breaths to calm down, just like Lance/Lucy. I don’t think the doctor was listening because I told her it doesn’t help. She said a psychiatrist could help me understand what was going on with how I’m feeling. I don’t understand. I felt like I was having a heart attack and she thinks I’m psycho.” “The episodes usually last about a half hour, but the last one was longer. (You are not sure how much longer). It was scary. I went to the ER. The doctor there said I was physically okay, but she didn’t seem to have any answers. She suggested I go see a psychiatrist, but I don’t understand how that will help.” “I’m terrified this is going to happen at work or when I’m driving, or during dance class – that would embarrass the girls.”

Onset Setting

Duration Time relationships Location Radiation Quality Amount Aggravated by what Relieved by what Associated with what

Attitude REVIEW OF SYSTEMS Screening for Agoraphobia

About 3 months ago. You were not doing anything out of the ordinary 3 months ago when this first happened. You started feeling shaky, had shortness of breath, and getting tunnel vision on your lunch break at work. It was an ordinary workday. 20 to 30 minutes Usually occurs once a week for the past 3 months It’s a whole-body feeling No radiation It’s hard to describe, but you can’t control the feeling of doom You are not able to rate it on a scale You have no idea; symptoms seem to come on at random times Nothing. Your spouse tells me to take deep slow breaths until it passes, but nothing seems to work. They start when they do and stop when they do.  Heart-beating really fast  Shortness of breath  Tunnel Vision  Sweaty and nauseous – last time You think it’s a physical problem, not a psychological problem. No to anything not associated with your current symptoms No to the following:

   

Using public transportation (bus or subway) Being alone outside your house Being in enclosed spaces or the opposite being in an open area Being in line or being in crowd

Your Triggers Your Triggers:  It’s has progressively gotten worse, and you feel husband/wife shouldn’t have to deal with this.  You don’t want him/her to think you’re “cracking up”.  There’s not enough time in the day to do everything you need to do.  Roger at work is getting on your last nerve. You feel he questions everything you do. You think he wants the lead position on the account and is undermining you. Psychiatric History Screen for Anxiety Disorders Is this something new or do you consider yourself something of a worrier in the past? Sometimes when folks worry, they also feel uptight and have muscle tension. Tell me about these nervous spells you’ve had these past couple of months.

Past Medical History Medication allergies Environmental allergies Illnesses Vaccinations Surgeries Accidents/injuries/trauma Hospitalizations Inclusive sexual and reproductive history Sexual practices Sexual partners Protections: use of safer sex practices Use of birth control if appropriate Risk of intimate partner violence Ob/GYN History

Medications Immunizations

 

Yes, you would consider yourself a worrier. Worried about everyday kind of things.

 

Yes, I get real tense sometimes. You feel everyone gets stressed out. It’s part of life.

        

You don’t think they’re nervous spells. Your heart pounds so fast, it hurts/chest pain. You get tunnel vision. You get shaky/your tremble/feel weak/faint You feel you have no control over these physical symptoms. You take deep breaths but can’t calm down. Sweaty/nauseous (last time) Lightheaded Numbness and tingling

None Seasonal for pollen. You do not take anything. (itchy eyes/runny nose) None Flu shot: every fall Wisdom teeth out at 16 None Male – none, Female – birth of children Heterosexual/lesbian/gay/bisexual/pansexual – can be any as long as it’s standardized Current: spouse, 2 past sexual partners in college Monogamous with partner; both tested for STIs when first dating May be modified based on sexual orientation. If heterosexual – use of oral contraception None Female:  Menses onset at age 14  2 pregnancies – both live births  No miscarriages  No abortions You take a daily vitamin and Motrin for the occasional headache.  Flu: every fall

Tobacco products: Alcohol  Wine Drugs  caffeine Diet Exercise List any other important social history or information important to the case Family History

Physical Exam Findings DIAGNOSIS AND DIFFERENTIAL MANAGEMENT OR DIAGNOSIC PLAN PROFESSIONALISM ISSUES OR CHALLENGES

 Tetanus: within the last 10 years  Hep B: yes None/never Rarely - a glass of wine if Lance/Lucy and you go out to a nice dinner – a handful of times a year since you’ve been married. 1 cup of coffee every morning since 18 years of age Regular diet, no change in diet recently. You avoid fried foods and limit sugar intake. No regular exercise routine, but you do a lot of walking around the office and take the stairs at work. No history of abuse. You grew up in northern Michigan. You remain close to your siblings and parents, talking with them on a weekly basis.  Mother – history of major depression, aunt as well  Father – diabetes type II  Brothers – 1 with history of anxiety. He takes some kind of medication for this. You are not sure what. Other 2 – alive and well  Paternal grandfather – history of colon cancer – died from this  Maternal grandmother – alive and well  Daughters – alive and well N/A N/A for case/SLO Student to discuss plan with you (patient) at the end of the encounter based on history See SP Checklist...