1.

History and mental status exam

Patient History

Identifying data:

Name: Julie

age: 48yo

sex: female

occupation: bank clerk

marital status: married

place of interview: clinic

Source of information: patient

Reliability: 90%

Chief complaint: “it’s my heart. I keep getting these situations where my heart starts to really, really
race”

History of Present Illness:

6 months prior to consultation patient reports experiencing palpitations associated with chest
pain and dyspnea on a hot day while going to town on her day off. She managed her symptoms by just
sitting down and waiting for her husband to pick her up. These reportedly happened around the time
where the patient was experiencing added stress from work due to pressure from having to learn a new
computer system installed at work. The patient, feeling anxious about her condition thought she would
be having a heart attack prompting her to seek consultation. An ECG was done with normal results.

On the day of consult, patient is still experiencing the same symptoms from time to time. This
has rendered her unable to leave her house without being accompanied by her husband. This has also
led her to avoid going out often, stop exercising, and stopped engaging in sexual activities with her
husband, thus prompting consultation.

Past medical history:

 No history of medical or psychiatric illnesses

 Unremarkable ECG Findings
 No history of surgical procedures

Family history:

 No record of familial diseases.

 Father died at 72 due to myocardial infarction

Personal and social history:

 Occupational history: Patient works as a bank clerk but is currently off sick from work
  Marital and Relationship: Patient’s husband is really supportive but has been getting fed up
recently
 Social Activity: Patient is a non-smoker and has been avoiding going out in fear of her symptoms
manifesting again.
 Sexual History: Patient has recently stopped engaging in sexual activities with her husband
afraid this might provoke her symptoms. She reports that her husband is getting frustrated with
it.
 Current living condition: Patient is living with her husband, stays at home, and has recently
avoided exercise, afraid this will put a strain on her heart

MENTAL STATUS EXAM:

Appearance

 Well groomed and appropriately dressed wearing casual clothes

 patient looks healthy and well-developed

Overt Behaviour

 Has been able to keep eye contact with interviewer

 hands are fidgeting for the duration of the entire interview
 No abnormal motor activity.
 Able to maintain eye contact.

Attitude

 cooperative and attentive, looks slightly tense.

Speech

 speaks english fluently and clearly with proper articulation. She speaks at a normal tone, rate,
and volume.

Mood and Affect

 The patient looks worried and anxious. Her affect is appropriate and congruent to her mood.

Thinking-

 Production: Able to produce thoughts well without poverty of thought nor thought blocking
 Form: Patient's thoughts were linear, goal-directed, and coherent
 Content: Patient expresses worries that her symptoms might lead to a heart attack.

Perceptions

 No perceptual disturbances noted

Sensorium and cognition

 Alertness: Patient was fully alert and awake during the interview
  Orientation and calculation: not assessed
 Coordination and memory: Able to remember important details like when her symptoms started
6 months ago and also the cause of death and the age of death of her father.
 Fund of knowledge: Adequate intellectual capacity
 Abstract reasoning: not assessed

Insight

 Patient is aware of her symptoms but is convinced that she might get a heart attack despite her
ECG having normal results.

Judgment

 The patient has good judgment as she is aware she needs help and is willing to get herself
treated.
2. Discussion of three differentials

Somatic symptom disorder — Patients with both panic disorder and somatic symptom disorder present
with multiple physical symptoms. Many patients with somatic symptom disorder also have comorbid
panic attacks or disorder. Some patients with somatic symptom disorder also met criteria for panic
disorder. However, somatic symptom preoccupation is more enduring with somatic symptom disorder
and more episodic with panic disorder.

Illness anxiety disorder — Illness anxiety disorder is defined in DSM-5 as individuals with high health
anxiety without somatic symptoms unless their health anxiety is better explained by a primary anxiety
disorder such as panic disorder. Many patients with panic disorder develop anxiety and fears of having a
serious medical illness such as HIV or cancer but can be differentiated from patients with illness anxiety
by also having multiple somatic symptoms such as tachycardia, chest pain and shortness of breath.

Substance abuse — Overuse of caffeine as well as abuse of stimulant drugs such as cocaine and
amphetamines can precipitate panic attacks. In addition, withdrawal from sedative hypnotics, alcohol,
and opiates can also precipitate panic attacks.

3. Discussion of the diagnosis

The apparent neurochemical dysfunction behind panic disorder may involve autonomic imbalance,
decreased gamma-aminobutyric acid (GABA)–ergic tone, [13] allelic polymorphism of the catechol-O-
methyltransferase (COMT) gene, increased adenosine receptor function, increased cortisol, [14]
diminished benzodiazepine receptor function, and disturbances in serotonin, [15] serotonin transporter
(5-HTTLPR) [16] and promoter (SLC6A4) genes, [17] norepinephrine, dopamine, cholecystokinin, and
interleukin 1–beta.

Panic attacks and panic disorder are common problems in both primary and psychiatric specialty care.
Panic attacks classically present with spontaneous, discrete episodes of intense fear that begin abruptly
and last for several minutes to an hour. In panic disorder, patients experience recurrent panic attacks, at
least some of which are not triggered or expected, and one month or more of either worry about future
attacks/consequences, or a significant maladaptive change in behavior related to the attacks, such as
avoidance of the precipitating circumstances.

An abrupt surge* of intense fear or intense discomfort that reaches a peak within minutes, and during
which time four or more of the following 13 symptoms occur:

4. Discussion of the treatment and management

Cognitive-behavioral therapy (CBT) helps patients to understand how automatic thoughts and false
beliefs/distortions lead to exaggerated emotional responses, such as anxiety, and how they can lead to
secondary behavioral consequences. CBT can be used alone or in addition to pharmacotherapy.

Pharmacotherapy

The American Psychiatric Association (APA) found insufficient evidence to either recommend any
pharmacologic intervention as superior to others for panic disorder or to routinely recommend
combination therapy over monotherapy. However, pharmacotherapy is recommended for patients who
prefer to be managed with medication or those who don’t have the time or other resources to
participate in psychosocial therapy.

SSRIs and TCAs

Selective serotonin reuptake inhibitors (SSRIs) (e.g., citalopram, escitalopram, fluoxetine, sertraline,
paroxetine and paroxetine controlled release, fluvoxamine

tricyclic antidepressant (TCAs) (e.g., imipramine, desipramine, nortriptyline, clomipramine).

Benzodiazepines (e.g., alprazolam, clonazepam, lorazepam)