Case Study: B.S. Dob: 12/25/1992 Gender: Female

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[. . .] Surgical: Appendectomy (2005) with no complications, 3 impacted wisdom teeth extracted (2006) with no complications. Lasik surgery OU (2007) with no complications except for onset of dry eye syndrome.

Psychiatric: Admits to obsessive compulsive tendencies but not diagnosed with obsessive compulsive disorder (OCD).

Vaccinations: Tetanus (2006), declines both flu and pneumovax. Has had all childhood required and recommended immunizations on schedule per records. Gardisil, Meningiococcal, Hepatitis C series, chicken pox vaccines completed. 2 step PPD was negative upon admission to university.

Family History:

Father- 50 yo, Hx: HTN

Paternal Grandfather- 72 yo, Hx: HTN, Diabetes

Paternal Grandmother- 70 yo, Hx: Uterine Cancer, HTN

Mother- 48 yo, Hx: Spinal surgery L5S1, HTN

Maternal Grandfather- deceased 68 yo- malignant melanoma

Paternal Grandmother_ 68 yo, Major Depressive Disorder, HTN

1 sister- 17 yo, denies any medical problems

1 brother- 16 yo, asthma, ADHD

Social History:

Pt lives on campus in a suite with three other women. During the summer she lives on campus and works in the genetic research lab. She has lots of friends and parental support. She participates on the track team and in the tutoring program at a local church. She is currently sexually active with one male partner of two years. She does not drink ETOH. She denies use of any tobacco products ever. She denies use of illicit drugs ever. She limits caffeine intake to one 8 oz. caffeinated beverage per day.

EXERCISE HISTORY:

Pt has participated on both high school and collegiate level track teams. She runs approximately 4 miles a day three days a week. She has been doing so for approximately 6 years. She uses the weight room 2 days a week for about 2 years.

NUTRITION:

Healthy, low fat diet

24h recall:

Breakfast- low fat French toast with strawberries and sliced almonds, skim milk

Snack- 2 cups air popped popcorn with small sprinkle of parmesan cheese and 10 dry roasted pecan halves, water

Lunch- tuna salad on spinach with diced apple and low cal mayo, water

Snack- 100 cal. Ice cream bar, water

Dinner- Veggie burger with Portobello mushroom, tomato and onion with multigrain flat bread, water

Ht: 5'8' Wt: 132 BMI: 19.8

Review of Systems (ROS): Because of the potential psychiatric issues here it would be best to do a full ROS to check for any odd or idiosyncratic complaints in conjunction with ruling out other differentia dx. Patients with psychiatric issues can be quite coy and present as rather normal, so it is best to do a complete formal evaluation and get a solid history. Always record odd or inconsistent symptoms.

Constitutional examination rationale: Looking for recent or unexplained weight loss, night sweats, fatigue/malaise/lethargy, appetite, recent trauma, unexplained falls consistent with thyroid (or other endocrine) dysfunction.

Eye rationale: Looking at visual changes, headache, double vision associated with seizures or diabetes or odd complaints.

Ears, nose, mouth, and throat rationale: Most interested in any nasal discharge, epistaxis, sinus pain, stuffy ears, ear pain, tinnitus, that could be associated with PE, ARDS, odd symptoms (psychiatric?), or seizure activity.

Neurological rationale: Rule out "special senses" (auras), changes in sight, smell, hearing and taste, seizures, fainting, blackouts, paraesthesiae, poor balance, speech problems, loss of consciousness, higher mental function and psychiatric symptoms. Here ruling out seizure disorder, other neurological issues, and psychiatric issues.

Cardiovascular rationale: Obviously the major complaint includes cardio sx, chest pain, shortness of breath, PND, orthopnoea, oedema, palpitations.

Respiratory rationale: Rule out PE and ARDS look at cough, sputum, wheeze, aemoptysis, shortness of breath in conjunction with these.

Gastrointestinal rationale: Any unintentional weight loss, abdominal pain, indigestion, bloating, cramping, anorexia, diarrhea/constipation, obstipation, or haematemesis.

Genitourinary/Urinary rationale: Most interested in incontinence, nocturia, and polyuria in association with diabetes (or odd sx).

Reproductive rationale: Cycle duration and frequency, irregularities, use of other birth control.

Musculoskeletal rationale: Would be most interested in odd or unusual sx.

Integumentary rationale: Any lesions, wounds (self-inflicted), dryness and/or sx associated with thyroid issues.

Endocrine rationale: Look for sx associated with hyperthyroidism preference for cool weather, sweaty, diarrhea, oligomenorrhoea, mood swings, weight loss despite increased appetite, etc. For diabetes: polydipsia, polyuria, or polyphagia. Any other odd sx.

Hematologic/lymphatic rationale: Any anemia, purpura, petechia.

Allergic/immunologic rationale: Any allergic reactions, odd sx, any reaction to contraceptives. Patient has no known allergies, but further clarification on her reaction to her contraceptive is needed.

Psychiatric rationale: Full evaluation needed; need clarification of what OCD sx/tendencies she displays and need to rule out any other psychiatric issues.

Diagnostic Tests: ROS, patient complaint, and patient history help rule out several of the differentials. Nonetheless, any patient complaining of chest pains should have BP/checked and be given an ECG regardless of the situation. Depending on those results further cardiac workup may or may not be needed. In this case it would also be important to check thyroid functioning and do a 12 panel drug screen via urine analysis just to be sure given there are potential psychiatric concerns. A psychiatric evaluation would also be pertinent here.

Differential Diagnosis:

Diagnosis

Pertinent Positives

Pertinent Negatives

MI

Chest Pain/shortness of breath

No tingling, numbness, left arm pain. Pain subsides with controlled breathing. Patient is young, physically active, denies substance usage, and in good shape.

AF

Chest Pain/Periods of rapid heart rate

Heart rate increases are situation specific (anxiety provoking situations). Decrease in sx with breathing exercise.

Atrial flutter

Periods of rapid heart rate

Heart rate increases situation specific (anxiety provoking situations). Decrease in sx with breathing exercise.

MVP

Anxiety, panic, some psychiatric sx.

Again it appears these sx are situation specific -- sx declines with controlled breathing

ARDS

Heart racing -- shortness of breath

Absence of trauma or recent surgery.

PE

Sudden onset of chest pain, shortness of breath

Patient is very active running several miles weekly. Sx with controlled breathing.

Hyperthyroidism

Heart racing, feeling nervous suddenly

Situation specificity of sx

Diabetes

Anxiety attack

No other sx consistent with this dx. Situation specific sx.

Seizure disorder

Anxiety sx.

No other reported sx that would suggest seizures such as blackouts, staring episodes, lost periods of time.

Intoxication, withdrawal, untoward medication effects

Lo/Ovral and oral contraceptives are known to precipitate panic attacks.

Denies drug, ETOH use. No formal evidence of intoxication from patient description.

Psychiatric disorder

OCD sx identified.

No formal psychiatric dx made at this time. Reality testing appears intact on examination. Patient does not appear manic or depressed.

Diagnosis: Panic attack. So far patient does not meet diagnostic criteria for panic disorder (requires recurrent panic attacks and we are not yet sure if the panic attack is related to her use of oral contraceptives, based on patient history it does not appear to be due to cardiac or pulmonary factors). Moreover, there is not enough information on the patient's psychological issues to determine if this attack is related to another psychiatric condition.

Pathophysiology: For panic disorder the Pathophysiology is unknown at this time. Suspected involvement of epinephrine triggering the fight-or-flight response in specific fear provoking situations leading to sympathetic nervous system arousal, vasoconstriction, dizziness and lightheadedness.

A genetic hypothesis of panic disorder has attempted to define specific genetic loci associated with the disorder, but it has been without success.

From a neuroanatomy standpoint it is believed that perhaps panic attacks are mediated by a fear network involving the amygdala, the hypothalamus, and brainstem. However this model is speculative at best.

Cognitive theories propose that people with panic disorder have a keen sensitivity to internal autonomic cues, but again this is speculative.

Evaluation, Education, and Health Promotion:

Until there is more information regarding this patient's psychiatric status the patient should be given a means to induce relaxation and breathing techniques to reduce any future reoccurrences. Patient should be referred to her psychologist as well as a psychiatrist for further evaluation and education.

References:

Afifi, T.O., Asmundson, G.J.G., Taylor, S., & Jang, K.L. (2010). The role of genes and environment on trauma exposure and posttraumatic stress disorder symptoms: a review of twin studies. Clinical Psychology Review, 30, 101-112.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: Author.

Andersson, G. (2011). Panic disorder. In W.T. O'Donohue & C. Draper (Eds.) Stepped Care and e-Health (pp. 61-76). New York: Springer.

Barlow, DH (Ed.). (2008). Clinical handbook of psychological disorders (4th ed.). New York: Guilford Press.

Cloos, J.M. (2005). The treatment of panic disorder. Current Opinions in Psychiatry, 18(1), 45-50.

Dains, J., Bauman, L., & Scheibel, P. (2012). Advance health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Elsevier Moby.

Eaton, W.W., Dryman, A., & Weissman, M.M. (1991). Panic and phobia. In L.N. Robins & D.A. Regier (Eds.), Psychiatric disorders in America (pp. 155 -- 179). New York: Free Press.

Fleet, R., Lesperance, F., Arsenault, A., Gregoire, J., Lavoie K., & Laurin C. (2005). Myocardial perfusion study of panic attacks in patients with coronary artery disease. American Journal of Cardiology, 96(8), 1064-1068.

Johnson, M.R., Lydiard, R.B., & Ballenger, J.C. (1995). Panic disorder: Pathophysiology and drug treatment. Drugs,… [END OF PREVIEW]

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