Case #23

Directions:
Click here to open your browser's e-mail system. This is where you will record your answers to questions plus any comments you want to pass along to your instructor. After entering your answers, you can check your response by clicking "Faculty Comments".  In the subject line of the e-mail form, enter your name and the name of the case being submitted, i.e., Case #23." When you finish your session with Family Medicine On-line, click the Send button in the e-mail window to forward your answers to your instructor. If you end your session before completing the case, click the Send button to submit your answers, and then exit your browser.

To complete the case during another session, go to the first page of the case and click the link above and then advance to the page where you left off. When finished with this session, click the Send button in the e-mail window. All materials copyrighted 2003 by Penn State University.

If you have completed Case W, this is a review and completion of this case will not be counted toward your assignment.

Chief Complaint

You are a family physician in a solo practice, which is owned and managed by the local hospital system. First on your schedule is Dr. Teresa Johnson, a 51 year-old African-American female. Her chief complaint is “sudden anxiety.” 

As you enter the examination room, Dr. Johnson immediately stands and reaches to shake your hand. “Good morning, doctor,” she says, “I am glad you were able to fit me in so soon.” 

You recall first meeting Dr. Johnson 22 years ago, within a month of starting your practice. At that time she was finishing up her Ph.D. in English at a local university, where she began teaching on a tenure track the following year. Over the subsequent years, you always felt a kind of kinship with her, as you progressed in your professional careers simultaneously. 

You ask your patient what brings her into the office today. She states that she experienced a very scary attack last evening – “I was sitting at home grading some essays and all of a sudden I started sweating, my heart started pounding and my breathing became tight. And just as fast as it came on, it went away! Nevertheless, I took two puffs on my inhaler which seemed to keep my breathing on par.”

 
  1. What additional questions do you have regarding her symptoms?

Review of Symptoms

Dr. Johnson states that all of the symptoms came on “out of the blue” and within 10 minutes had completely disappeared.  Her only additional complaint during this time was feeling “overly anxious…like I was crawling out of my skin.”  She states that despite her lifelong struggle with anxiety, nothing this severe or sudden has ever happened before. 

You review Dr. Johnson’s medical record. 

PROBLEM LIST

  • hypothyroidism since age 32

  • generalized anxiety disorder since late 20s

  • asthma since age 16

  • slightly overweight

  • cesarean section X2

 ALLERGIES

  • NKDA

MEDICATIONS

  • MVI

  • synthroid 225ug qd

  • albuterol MDI – 2 puffs PRN

  1. In determining the cause for Mrs. Johnson’s anxiety, what broad, general categories will you include in your differential diagnosis?
  2. How does the primary care physician begin to determine the cause of the anxiety symptoms?
  3. What specific medications or medical conditions in Dr. Johnson could be the cause of her anxious feelings?

Physical Exam

You look in Dr. Johnson’s chart and note that her TSH and T4 were checked last month at her yearly physical – the values were normal at  5.0  and 1.2, respectively.  Dr. Johnson states that her asthma is mild and under control, and she last had to use her inhaler 3 or 4 months ago.  She denies using her inhaler more than once or twice when she has an attack.  She denies having any symptoms of menopause at this time. 

Her physical exam reveals no abnormalities:

Vital Signs: BP 134/84, P 62, R 12, T 37C

General – mildly overweight female in NAD

HEENT - NC/NT, PERL, EOMI, tympanic membranes white with + light reflexes, nares patent, pharynx pink, moist mucus membranes

Neck - supple, no nodes, no bruits, no thyromegaly and no thyroid nodules noted

Heart - RRR with no murmur

Chest - CTA B/L with no rales or wheezes

Abdomen - soft, NT/ND with normoactive BS, no HSM

Neuro- CNs II-XII intact B/L, strength 5/5 UE and LE B/L, biceps and patellar reflexes 2+ B/L, sensation to light touch and pinprick intact UE and LE B/L, no tremor, cerebellum intact B/L (finger to nose and heel to shin), Romberg negative, gait straight with no assistance

Skin- no rashes, mild eczema on arms B/L. 

An EKG done in the office is normal.

  1. Expand your differential and compose a more comprehensive list of the medical causes of anxiety.

Studies have shown that among patients referred to a psychiatrist for management of anxiety, up to 4 out of 10 have been found to have an underlying medical illness responsible for the anxiety.

 
  1. Substance-Induced Anxiety Disorder can be caused by the use or withdrawal of numerous drugs. What prescription medications are correlated with symptoms of anxiety?
  2. Intoxication with what substances and illicit drugs are correlated with symptoms of anxiety?
  3. Withdrawal of what substances and illicit drugs often produces symptoms of anxiety?

Social History

Physicians often are reluctant to take a thorough drug history in patients they have known for years.  However, in order to provide objective and comprehensive care, it is necessary to inquire about substance use and/or abuse. 

You broach the subject with Dr. Johnson, “As I consider all the possible causes of anxiety there are a number of questions that I ask all my patients.  About how much alcohol do you drink in a week?” 

Your patient replies, “I usually have a glass of wine with dinner on the weekends.” 

“When is the last time you had more than one or two glasses of wine at a time?” 

“Oh heavens, probably in my college days!” 

“Teresa, I know you have been struggling with trying to lose weight over the past few years.  Have you ever taken over-the-counter diet pills?” 

“Actually I did try those years ago, but they kept me up at night – but like I said, that was at least 5 years ago.” 

“And have you used any other substances or drugs?” 

“Just what you prescribe.”

At this point you start to consider a primary psychiatric diagnosis.
 
  1. What are the different types of primary psychiatric anxiety disorders?
  2. How does anxiety manifest?
  3. What neurotransmitters are associated with anxiety?
  4. What areas of the brain are implicated in the production of anxiety?
  5. How common are primary anxiety disorders in the general population?
  6. How common are anxiety disorders in primary care practices?
You recall that Dr. Johnson has struggled with generalized anxiety over the years. She periodically complains of feeling on edge and “stressed,” with muscle tension and difficulty sleeping. However, she often attributes these feeling to her responsibilities balancing a career and a family.

You briefly look through Dr. Johnson’s medical record to review her course of GAD.   She recalls being an anxious person from the time she was in junior high.  However, she excelled in high school academics and extra-curricular activities such as drama and track.  She recalls that “running helped to keep me relaxed and focused.” 

During her junior year in college she remembers having difficulty controlling her worry.  The fall semester was so bad that she had difficulty sleeping, was tired all day and had problems with loose bowels – “the school nurse kept asking me if I took laxatives!”  In order to get through her exams she was on “some sort of a sleeping pill” which alleviated her anxiety.  However, she states the “I was only allowed to be on that for about two weeks”. 

During the remainder of her education and during her first few years working as Assistant Professor of English, she states she used her feelings of worry to push herself to excel academically.  During her forties, however, her perpetual worry started to have a negative impact on her life.  “I worried about my finances, I worried about my parents’ health and I worried about my husband and kids.  There were days that I felt as though I just couldn’t function as I used to…as I needed to.” 

During this time, her yearly physicals revealed no abnormal findings aside for moderate weight gains.  Appropriate laboratory work also was within the normal limits, including her thyroid function. 

Your recall that Dr. Johnson saw a masters-level cognitive therapist over the past 10 years.  However, she was initially apprehensive about taking medication for her anxiety – “what if they find out at work that I need pills to keep me calm?”   And while the cognitive therapy helped her cope with her symptoms, she found that her anxiety and worry were preventing her from enjoying life to the fullest.  She finally agreed to a medication trial about five years ago.

 
  1. What are the diagnostic criteria for Generalized Anxiety Disorder (GAD)?
  2. What is the epidemiology of GAD?
  3. What is the course, including onset, of GAD?
  4. What do the symptoms appear to be consistent with?
  5. Are Panic Attacks and Panic Disorder the same thing? Explain.
  6. When does Panic Disorder usually present?
  7. What is the course of Panic Disorder?
  8. What is the lifetime prevalence of Panic Disorder?
  9. What familial patterns are seen in Panic Disorder and GAD?
  10. Anxiety is a symptom seen in numerous other psychiatric disorders. What other primary psychiatric disorders are in our differential?
  11. What categories of drugs can be used in the treatment of Panic Attacks and Panic Disorder?
  12. How do the benzodiazepines decrease anxiety?
  13. Categorize the benzodiazepines commonly used in treating anxiety disorders in the following categories:
    1- high-potency, short-acting
    2- high-potency, long-acting
    3- low-potency, short-acting
    4- low-potency, long-acting
  14. How do the benzodiazepines decrease anxiety?

 

You continue in your discussion with Dr. Johnson.  As she has experienced only one episode that appears to be a panic attack, you explain that no medications are indicated at this time.  You also reassure her that her heart exam, EKG and lung exam are normal.   You also remind her of her normal thyroid values obtained at her last visit. 

However, you re-evaluate her symptoms of generalized anxiety.  At her appointment last month, she described feeling slightly more worried than last year at this time, but could not pinpoint any reason for the worry.   She described experiencing fatigue during the day with associated muscle tension.  She also had been having increased frequency of bowel movements.  (Note: she was heme negative at her last visit).  

She has been using relaxation tapes in the evening and deep breathing exercises during particularly stressful days.  However, she feels as if her low-level anxiety is persisting longer than usual. 

Dr. Johnson then asks about a drug she saw advertised in one of her magazines – “ I read that BuSpar is a great medicine for anxiety – and they said it doesn’t have many side effects.”
 
  1. What do you tell your patient about buspirone (BuSpar)?
At this point you decide to begin your patient on buspirone (Buspar) 5mg tid. You also prescribe diazepam (Valium) 5mg tid, with the plan to discontinue the Valium after 2 weeks. You advise her to refrain from driving until she determines the effect the Valium has on her coordination.

 
  1. What routine laboratory studies do you order before and during treatment with buspirone (BuSpar)? with benzodiazepines?

Continue to next page



Penn State Milton S. Hershey Medical Center ©2004
This page was last updated on April 24, 2006
Contact Us