Case Analysis and Diagnosis of Maria’s Condition

QUESTION

Maria, aged 25 has been referred to you by her PCP and cardiologist for evaluation and treatment. She tells you, “They tell me nothing is wrong with me, all these physical things are just in my head.”

Maria tells you she has 4 emergency room visits in the last 3 months for episodes of her heart racing, feeling like “it’s skipping beats”, shortness of breath, sweaty and shakiness. She cannot relate these to any particular cause as they come on fairly suddenly. She is not sure how long they actually last but she estimates 10-15 minutes. Afterwards she feels “physically & emotionally spent.” She is afraid she is having a heart attack and like she is going to die. The attacks have happened at home, work, and some social engagements. Her last attack woke her from sleep; this made her more fearful than ever and her PCP suggested she see you.

She had cardiac testing done that included several EKGs, and an angiogram and all were normal. She had lab work done at her PCP office and it was all normal including a TSH of 2.2 mm/l. She has copies of her labs with her. She is concerned because she is increasingly fearful about having these attacks to the point that it is affecting her work, (she has had to leave work early after having attacks while at work). She has also turned down social engagements due to her fear of having these attacks.

Maria is single, lives by herself in a rented apartment. She works as medical biller at a local medical office and attends college classes 2 nights a week. She has a boyfriend, but she doesn’t think it is serious yet. She has several close female friends she sees after work and talks to frequently. She is the middle child, she has an older brother and younger sister. Her father lives close by. Her mother died of a suicide by overdose when Maria was 12 years old. She was the one who found her mother’s body. She feels like her relationship with her family is “good”.

Her past medical history is negative for anything, she takes no medications and denies any allergies. Her father is treated for high blood pressure. Her mother had a history of depression included several hospitalizations for this prior to her death.

She denies any psychiatric history except “school phobia” when she was a teen ager, but it got better by the time she finished high school. She did not receive any treatment for this.

Physical Exam

She is alert and oriented x3 spheres. Vital signs, T 98.6, Pulse 72, R. 18, BP 108/60, Weight 135#, Ht. 5’5″, BMI 22.5

Cardiac: RRR S1S2 no murmur, no edema

Respiratory: Chest Clear, easy even and quiet

Neck: No lymphadenopathy or thyromegaly

Neuro: Gait steady, full ROJM, Mood and affect congruent, CN 2-12 intact

Mental Status Exam

Direct Eye contact

Answers questions appropriately, Speech became slightly pressured when she was talking about her “attacks”.

Clothing was clean and appropriate for season. No tattoos or scars. Earrings in both ears.

Sat quietly during most of the exam. Bounced her left foot when discussing her symptoms.

Denies wanting to hurt self or others.

Insight is good. “I just want to get to the bottom of this. If it isn’t physical, something is causing this. I want my life back!”

PHQ-9 Score was 6

QUESTIONS

Any additional information you think you need to assist you in this case?

· Additional Assessments you need, why or why not

i. Screening Tools

ii. Diagnostic Testing

· Your Diagnosis

i. The ICD-10, including any specifiers if applicable

ii. Must document the DSM 5 criteria that support your diagnosis

· Differential Diagnosis if applicable

· Pathophysiology of the condition

· Your Treatment Plan

· Psychotherapeutic Modalities

· Psychosocial Interventions

· Medications

o Must include dose, directions, possible major side effects, any drug interactions, if applicable

· Education

· Follow-up

ANSWER

Case Analysis and Diagnosis of Maria’s Condition

Introduction

Maria, a 25-year-old woman, has been experiencing recurrent episodes of rapid heart rate, palpitations, shortness of breath, sweating, and shakiness, often accompanied by a profound fear of having a heart attack. These episodes have led to multiple emergency room visits, impacting her work and social life. Despite undergoing cardiac tests that yielded normal results, Maria’s distress continues. This essay aims to analyze Maria’s case, establish a diagnosis, discuss potential differential diagnoses, delve into the pathophysiology of her condition, outline a treatment plan, and propose therapeutic modalities.

Additional Information and Assessments

Psychiatric History: Maria reports a history of “school phobia” during her teenage years, which eventually improved without treatment. Further exploration of this history may be needed to assess its relevance to her current condition.

Family History: Maria’s mother died of a suicide by overdose, and she discovered her mother’s body. This traumatic event may contribute to her current symptoms and should be explored further.

Diagnosis

Panic Disorder with Agoraphobia (ICD-10: F41.0)

DSM-5 Criteria

Recurrent unexpected panic attacks.
Persistent concern about having additional attacks.
A significant maladaptive change in behavior related to the attacks (avoidance of situations).
Symptoms are not due to the direct physiological effects of a substance or another medical condition.

Differential Diagnosis

Generalized Anxiety Disorder (GAD): While GAD can present with excessive worry and physical symptoms, panic attacks with agoraphobia better capture Maria’s fear during these episodes.

Hyperthyroidism: Although Maria’s thyroid function test was normal, thyroid disorders should be considered due to her anxiety-related symptoms.

Pathophysiology

Panic disorder is believed to result from a combination of genetic, neurological, and environmental factors. Dysregulation of neurotransmitters, particularly serotonin and norepinephrine, plays a role in the development of panic attacks. Traumatic experiences, such as the loss of her mother, can trigger panic disorder.

Treatment Plan

Psychotherapeutic Modalities: Cognitive-Behavioral Therapy (CBT) with a focus on exposure therapy and cognitive restructuring.
Psychosocial Interventions: Supportive counseling and psychoeducation about panic disorder and grief.
Medications

Selective Serotonin Reuptake Inhibitors (SSRIs): Initiate sertraline 25 mg daily, titrating to 50-100 mg daily. Monitor for side effects.
Benzodiazepines (Short-term): Clonazepam 0.25 mg PRN for acute panic attacks.

Education: Provide information on panic disorder, coping strategies, and the importance of adherence to treatment.

Follow-up: Schedule weekly therapy sessions for the first month, then monthly follow-ups to assess progress.

Conclusion

Maria’s case demonstrates the complexity of mental health conditions, where physical symptoms can often have underlying psychological causes. A comprehensive assessment, including her traumatic history, supports the diagnosis of panic disorder with agoraphobia. With a multidimensional treatment plan that includes psychotherapy, medication, and education, Maria has a good chance of managing her condition and regaining control over her life. However, continuous support and follow-up will be essential in her journey towards recovery.