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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • List common presenting symptoms of panic disorder

  • Identify the desired therapeutic outcomes for patients with panic disorder

  • Discuss appropriate lifestyle modifications and over-the-counter medication use

  • Develop a monitoring plan for anxiety patients placed on specific medications

  • Educate patients about their disease state and appropriate lifestyle modifications, psychotherapy, and pharmacotherapy for effective treatment

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PATIENT PRESENTATION

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Chief Complaint

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"I think I'm going crazy. I get this tightness in my chest, my heart races and I feel like I am going to die."

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History of Present Illness

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Angela Brown is a 32-year-old woman who presents to her primary care physician complaining of sudden episodes of fearfulness accompanied by a tightening in her chest and intense anxiety. During these episodes she has heart palpitations, nausea, sweating, and a fear "that I'm going to die." They "just come out of nowhere" and last 10–15 minutes. She reports experiencing 2–3 episodes a week for the past few months. She recalls having her first episode like this approximately 3 years ago after the death of her father. Over the past 6–8 months they have increased in frequency and intensity. She has gone to the ED twice in the past 6 months as she felt something was wrong with her heart, but was told her heart was fine and it was probably stress. Her "ECG and blood tests were normal." She was given a prescription for diazepam 5 mg PO as needed and told she should schedule an appointment with her regular doctor.

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She reports worrying a lot about her job, finances, children, and her health. She reports feeling sad, irritable and tense, and has difficulty sleeping. She is very fearful of having another episode and has started to avoid places like Wal-mart, and the mall, where these have occurred. She has difficulty attending after school events where "everyone is in the gymnasium and I'm afraid I can't get out." She called in sick the day of the holiday performance but fears she will be in trouble at work if this continues.

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Past Medical History

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Migraine headaches diagnosed 5 years ago

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Depression 3 years ago following father's death; resolved with psychotherapy

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Family History

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Father died at age 54 in a motor vehicle accident. Mother diagnosed Stage 1 breast cancer 14 months ago, s/p lumpectomy with good prognosis. She has one sister who has "anxiety" and is on citalopram.

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Social History

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She grew up in southern Colorado with both parents and one younger sibling. College graduate with a degree in secondary education. Currently employed as an art teacher at the local high school. Happily married with a 2-year-old daughter. Few social activities outside of work.

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Tobacco/Alcohol/Substance Use

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