Allen, a university graduate aged 21 years, attends the pharmacy of the campus counseling health center and asks to speak to the pharmacist in private. He states he is worried about heart palpitations that he has been experiencing. He is visibly sweating and looks on edge. The pharmacist calls the provider on duty at the psychiatric clinic for the counseling health center and she arrives.
Assessment
As the PMHNP on duty, you invite Allen into the consultation room and ask him about his symptoms. He states that he has started a new job and that the palpitations start when he is feeling anxious. His symptoms are occurring most days of the week and he says it makes him “feel on edge.” He adds that he does not want to socialize with his co-workers. It is starting to affect his sleep and he does not know what to do. He also states that he has occasional pain in his chest.
Treatment options
Allen is demonstrating symptoms of moderate anxiety, given his desire to avoid socializing, and has a degree of functional impairment. However, as he has potential cardiac symptoms, these issues could be related to another condition.
When questioned, he confirms he has no other problems with his health, but you feel the patient needs further investigation. For example, tests to measure the electrical activity of his heart to rule out underlying cardiac problems should be considered. His presentation concerns you and you feel he needs these tests today to assess the differential diagnosis, as you are worried about his chest pain and palpitations.
Vitals:
138/80
4
20
78
99%
5’10”
188 lbs.
Advice and recommendations
You encourage Allen by saying that it is great that he felt he could talk to a pharmacist about this, but explain that he would benefit from continued management with you as the PMHNP and possibly some additional psychotherapy. You explain that his symptoms could be related to anxiety and that you think he may need something to help him manage. He agrees to let you continue the assessment and design a treatment plan.
Full Answer Section
- Panic Disorder: While less likely, his heart palpitations and sudden onset of anxiety could point towards panic disorder.
- Social Anxiety Disorder: Avoiding social interactions suggests potential social anxiety, coexisting with GAD.
- Underlying Medical Conditions: Chest pain warrants ruling out cardiac problems like tachycardia or arrhythmias. Thyroid dysfunction and medication interactions should also be considered.
Diagnostic Workup:
Given the potential for both psychiatric and medical causes, a comprehensive approach is crucial:
- Physical Examination: Assess vital signs, listen to heart sounds, and conduct a general physical examination.
- Laboratory Tests: Order blood tests to evaluate thyroid function and rule out other medical conditions.
- Electrocardiogram (ECG): Assess cardiac rhythm and electrical activity to identify any abnormalities.
- Anxiety Screening Tools: Utilize standardized questionnaires like the Generalized Anxiety Disorder-7 (GAD-7) to quantify symptom severity.
Treatment Plan:
Based on the diagnostic workup, the treatment plan for Allen may involve:
- Psychotherapy: Cognitive-behavioral therapy (CBT) is highly effective for managing anxiety disorders. Individual sessions would help Allen identify and challenge negative thought patterns and develop coping mechanisms for anxiety.
- Medication: Depending on the severity of symptoms and response to psychotherapy, a short-term course of anxiolytics like benzodiazepines or selective serotonin reuptake inhibitors (SSRIs) could be considered.
- Stress Management Techniques: Techniques like relaxation exercises, mindfulness meditation, and deep breathing can help Allen manage anxiety symptoms in the moment.
- Education: Provide Allen with information about anxiety disorders, their causes, and effective treatment options.
- Support Network: Encourage Allen to seek support from friends, family, or university support services.
Addressing Chest Pain:
The chest pain warrants prompt attention. If ruled out as physical, it could be a somatic symptom associated with anxiety. However, ruling out any underlying medical cause is crucial before solely attributing it to anxiety.
**Considerations for **
- Schedule regular follow-up appointments to monitor Allen's progress and adjust the treatment plan as needed.
- Closely monitor for potential medication side effects.
- Consider collaborating with Allen's general practitioner or cardiologist if necessary.
Conclusion:
Allen's case requires a holistic approach that addresses both his psychological and physical needs. By conducting a comprehensive assessment, ruling out medical concerns, and providing a multi-faceted treatment plan, you can guide Allen towards managing his anxiety and improving his overall well-being.
Additional Notes:
- This case study is for educational purposes only and does not constitute medical advice. Consulting with a qualified healthcare professional is essential for proper diagnosis and treatment of any medical or mental health condition.
- The suggested treatment options are examples and may vary depending on individual circumstances and response to interventions.
- Providing Allen with resources and support networks empowers him to actively participate in his recovery journey.
Sample Answer
This case study presents Allen, a 21-year-old university graduate experiencing heart palpitations, anxiety, and social withdrawal. As the PMHNP, your primary concern is ensuring Allen's well-being and developing a comprehensive treatment plan that addresses both his immediate needs and potential underlying issues.
Differential Diagnosis:
While Allen's symptoms strongly suggest moderate anxiety, the presence of chest pain and his concerns regarding new stressors like his job require careful consideration of other possibilities. The differential diagnosis may include:
- Generalized Anxiety Disorder (GAD): Allen's frequent anxiety, sleep disturbance, and physical symptoms fit the diagnostic criteria for GAD.