Subjective
The chief complaint of the patient is having a horrible feeling in the chest. The patient, a 36-year-old Caucasian man with a history of asthma, complains of acute, persistent chest pain that started two weeks ago when he was working out at the gym. He claims that since that incident, the chest pain has steadily gotten worse without any apparent triggers, but has instead turned into commonplace symptoms that have mostly happened at work. However, this time the chest pain struck while he was relaxing and watching television. His chest pain primarily radiates under his chest, is gripping and squeezing with pressure around his entire chest, has lasted for 20 minutes as opposed to the initial 5 minutes2.4, is non-replicable, and is accompanied by vomiting, sweating, shortness of breath, dizziness, and feelings of choking. There were no aggravating nor alleviating variables noted. Of note, the patient is very worried, worrying that there is “a lit fuse waiting to blow up in his chest, as he saw his father drop dead of a heart attack two years ago. The patient has a history of asthma but has denied any past issues of mental health conditions. The patient as we as denied any issue of concern about getting any surgical procedure. The patient denies any issues of allergic reaction.
In terms of social history, the patient has a girlfriend but is not married and does not have any children. He rates the connection as excellent. He is a financial planner and holds a bachelor’s degree in finance. Does he acknowledge that he has two to three drinks during the week and a few more on Fridays and Saturdays? The amount of alcohol he admitted to consuming last night, maybe five drinks spread out over 4-6 hours, was unusual for him. Additionally, he stated that he began smoking a half-pack of cigarettes a day when he was 20 years old. Last but not least, he revealed that he has two cups of coffee in the morning and one to two diet sodas in the afternoon. The patient has reported that his father died at the age of 62 years of myocardial infarction. His mother is alive and his grandfather is dead and died of myocardial infarction. His uncle as well died of the same disease. He has reported that he has 2 brothers, who are 34 and 38 years old.
Include chief complaint, subjective information from the patient, names and relations of others present in the interview, and basic demographic information of the patient. HPI, Past Medical and Psychiatric History, Social History.
Objective
The patient has been observed and it is found that there is no indication of weight loss, neuralgia, temperature, colds, and rigors. The patient admits to having dizziness; however, he denies seizures, ataxia, fainting, numbness/ tingling. The patient as well as pointed out that he has anxiety and fear of suffering a heart attack. Denies depression, nervousness, and difficulty sleeping. The patient has been observed to be fine dressed, well-groomed, and well-nourished.
The tests that are undertaken include :
basic laboratory test (serial troponins, chest x-ray, and electrocardiogram) were all within normal limits.
Urine toxicology: Negative
About the issue of mental examination of the patient, it is found that the patient has AAOx4, Fair eye contact. Regarding speech, it is found that the patient is slightly fast-paced speech There has not been a test on the memory of the patient on the issue of psychomotor it is found that he has a mild postural tremor, fidgeting of hands and legs. The patient is scared and that he is anxious. The thought content of the patient is that he has denied suicidal ideation/homicidal ideation. It is found that the patient has thoughts that are logical and linear and there is no indication of having an issue of poor Judgment. He can sustain attention, follows commands, working memory intact
This is where the “facts” are located. Include relevant labs, test results, vitals, and Review of Systems (ROS) – if ROS is negative, “ROS noncontributory,” or “ROS negative except…” Include MSE, risk assessment here, and psychiatric screening measure results.
Assessment
The patient was a 36-year-old Caucasian male with no significant medical history and presented with acute chronic chest pain during exercise a month ago. These symptoms occur regularly, usually at work, now at rest, with daily symptoms. Symptoms of chest pain are non-radioactive, non-reproducible, 8/10 pain, vomiting, sweating, shortness of breath, dizziness, and choking sensation, squeezing and squeezing the entire chest, varying from 5 to 20 minutes. No factors have been reported to exacerbate or mitigate. The patient’s psychological history is inconspicuous. However, he lived to see his father die of myocardial infarction two years ago at the age of 64 and persistently treated all the men in his family who also died. He finds it difficult for patients to stop exercising and focus on their work because he is obsessed with “flaming fuses waiting to explode in his chest.” Patients’ heart risk factors include a family history of myocardial infarction and unhealthy behavior such as drinking large amounts of caffeine, smoking daily, drinking on weekdays, and drinking excessively on weekends. After all, his current daily stress factor is work pressure because financial markets aren’t working well.
The differential diagnosis was substance use disorder, nicotine addiction, and panic disorder with asthma. F41.0 Panic Disorder: According to the American Psychiatric Association (APA, 2013, p. 208), panic disorder (agoraphobia) is an anxiety disorder that is primarily based on the experience of repetitive and often sudden panic attacks. Panic about one seizure and subsequent seizures for more than a month. This changes people’s behavior. This often involves avoiding situations that could trigger another attack. Panic attacks are manifested by four or more symptoms: throbbing, sweating, shivering or shivering, shortness of breath or choking sensation, choking sensation, nausea, dizziness, and fear of death. Patients lack insight into their fears. Therefore, peace of mind and psychoeducation alone are not enough. (F41.0). Panic Disorder Objective: The client reports panic attack / symptom relief within 1 month of treatment. Intervention: Education on the importance of panic attacks and smoking cessation, alcohol withdrawal, and reduced caffeine consumption. (F 17.200) Nicotine Addiction Objective: The client reports that he has stopped using tobacco within a month of treatment. Intervention: Clients are educated about the association between smoking and the increased risk of developing or increasing anxiety (Moylan, Jacka, Pasco, and Berk, 2013). Start with daily administration of 21 mg of nicotine transdermal patch for 6 weeks. According to Wadgave and Nagesh (2016), nicotine replacement therapy (NRT) reduces the craving for tobacco use and nicotine withdrawal symptoms, thereby facilitating the transition from smoking to complete abstinence.
(305.10) Substance Use Disorder
Goals: Clients Report Avoid alcohol consumption and reduce caffeine consumption Within 1 month of treatment. Intervention: The patient Get informed about self-medication for comorbidities Anxiety and alcohol use disorders. This model is for people with anxiety disorders try to mitigate their adverse effects Illness caused by drinking alcohol to finally manage the symptoms As a result, alcohol use disorders develop later (Smith, & amp; Randall, 2012). In addition, customers will be notified about connections between Exciting consequences of overdose and deterioration of caffeine Anxiety symptoms.
Include your findings, diagnosis, and differentials (DSM-5 and any other medical diagnosis) along with ICD-10 codes, treatment options, and patient input regarding treatment options (if possible), including obstacles to treatment.
Plan
Start with escitalopram (Lexapro) 5mgpo daily. According to Townsend & Conrad (2017), escitalopram is the most effective SSRI, and a set of evidence suggests great value in the treatment of panic disorder. Start with Hydroxyzine (Vistaril) 50 mg / PRN every 6 hours. (Short-term use) Until SSRI becomes effective.
Cognitive behavioral therapy can be provided with or without concomitant pharmacological treatment. CBT includes psychoeducation regarding the symptoms of panic disorder as the manifestations of dysfunction within the body’s sympathetic-response system (flight or fight). The patient learns that the perception of even mild physiologic symptoms may be internally misinterpreted as signs of threat, illness, or impending doom. This misinterpretation triggers escalating worry followed by progressive worsening of symptoms associated with the activated sympathetic system; e.g., sweating, tensing of muscles, dizziness, heart racing, shortness of breath.
CBT relaxation techniques include diaphragmatic breathing, progressive muscle relaxation, and scenic imagery. Relaxation techniques augment other aspects of CBT such as the challenging of negative styles of thinking and the systematic exposure to avoided situations and uncomfortable physical sensations that may have triggered panic attacks. As systematic exposure increases, patients are able to progressively expose themselves to triggers without worry or fear of harm; this subsequently reduces the severity and frequency of panic attacks
Clients check in to their GP as needed to continuously monitor asthma symptoms and / or interventions. Clients recognize the link between smoking and cardiopulmonary disease and the importance of abstinence. Patients start Antabuse (disulfiram) 250 mg po daily x weeks 1-2 weeks, followed by 250-500 mg po daily until tolerance is lost. According to the National Mental Illness Family Alliance (2018), disulfiram is a drug used to treat alcoholism. Disulfiram works by blocking the breakdown of alcohol in the body. This leads to the accumulation of toxic alcohol-related compounds, which can be very ill for people who drink alcohol while taking this medicine. This effect helps people avoid alcohol while taking prescriptions. Finally, it has been observed to be more effective in the administration and prevention of alcoholism compared to acamprosate (camprosate) (Diehl, A. Ulmer, L. Mutschler, J. Herre, H. Krumm, B. Croissant, B. Mann, K. & Kiefer, F. 2010)
Include a specific plan, including medications & dosing & titration considerations, lab work ordered, referrals to psychiatric and medical providers, therapy recommendations, holistic options, and complementary therapies, and rationale for your decisions. Include when you will want to see the patient next. This comprehensive plan should relate directly to your Assessment.
References
Panic Disorder. Rockville Concierge Doctors. Retrieved from: https://www.rockvilleconciergedocs.com/PatientEducation/tabid/40343/ctl/View/mid/86303/Def ault?ContentPubID=304
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental Bdisorders (5th ed.). American Psychiatric Publishing, Inc.
Stahl, S. (2017). Essential Psychopharmacology: Prescriber’s Guide (6th ed.) Cambridge, England: Cambridge University Press.
Gurvinder, K., De Sousa, A, Shrivastava, A. (2014)”Disulfiram in the management of alcohol dependence: A comprehensive clinical review “. Open Journal of Psychiatry, Vol.4 No.1,
2014. Retrieved from: https://www.scirp.org/journal/PaperInformation.aspx?PaperID=41667
Moylan, S., Jacka, F.N., Pasco, J.A. et al. Cigarette smoking, nicotine dependence, and anxiety disorders: a systematic review of population-based, epidemiological studies. BMC Med 10, 123 (2012). https://doi.org/10.1186/1741-7015-10-123
What is a mental disorder? (n.d). Abnormal Psychology. Lumen. Retrieved from:
https://courses.lumenlearning.com/wm-abnormalpsych/chapter/what-are-mental-disorder s/
Smith, J. P., & Randall, C. L. (2012). Anxiety and alcohol use disorders: Comorbidity and treatment considerations. Alcohol Research: Current Reviews, 34(4), 414–431. Retrieved from: https://psycnet.apa.org/record/2013-28231-006
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