Question

A 58 yr. old female school teacher with heart disease and a recent heart attack 6 months ago presents to ER with a complain of heart palpitation, chest discomfort and SOB. She appears anxious and asks repeatedly “Am I having another heart attack?!” Denies any triggers to her symptoms and reports “it all started out of nowhere.” Since her heart attack 6 months ago, she has suffered from several of these symptoms. She has extended her medical leave of absence from work. She denies use of substance and quit smoking 6 months ago after the heart attack.

Mental status examination reveals an obese, anxious woman who speaks hurriedly between breathes. Vital signs reveal tachycardia and tachypnea. Cardiac examination also demonstrates a rapid rate with an irregular rhythm. The remainder of the physical examination is unremarkable.

• Describe the conditions that will need to be ruled out before a psychiatric diagnosis can be made.

• Discuss any diagnostic work up you think is necessary, provide your rational.

• Does the patient require psychiatric hospitalization? What's your rationale for your decision?

• Discuss your most likely diagnosis with the evidence to support your decision

Answer 1

The patient will be ruled out for another heart attack episode or for myocardial infarction or is the symptoms related with gastrointestinal system which usually mimic symptoms of cardiovascular system.To assess tge patient for any respiratory illness

The following diagnostic test like

• Blood test for CPK MB to rule out any muscle or tissue injury of heart
• Oxygen saturation test, Chest X ray,Pulmonary function test
• Mental status examination to rule out the actual cause of anxiousness

The patient needs a psychological support if the symptoms persists to CNS A hospitalization is generally required at this time because patient is experiencing breathlessness and the psychotherapy to be started.When psychiatric medicines are administered the effects may be immediate and patient to be assessed for any side effects and complications due to medication

The most likely diagnosis is anxiety disorder ( due to medical condition), where patient experiences the above symptoms(repeated thinking of chest discomfort, palpitations, fear of getting another episode of a disease or feeling of experiencing the same discomfort ,increased heart rate and respiratory rate,  The pain and discomfort at times can be phantom.These makes the patient to be suspected for psychiatric issue.