Identifying information: 49-year-old Asian-American female
Setting: Outpatient mental health clinic.
Chief Complaint/Reason for visit: “I can barely stand going into public anymore, not even to go shopping. My heart condition makes it hard for me.”
History of Present Illness: LL presents to the clinic today at the urging of her PCP for evaluation of her anxiety, racing heart, feelings of impending
doom for the past six months. LL reports that last March, she started to experience episodes of racing heart, tunnel vision, a sense “that I am in a
dream”, and shortness of breath, lasting 5-10 minutes. LL reports being “really worried that I have a heart condition, and no one is diagnosing it
correctly”. She endorses increased “fretting and worrying about the state of the world”.Her symptoms started, she said, after a shooting last Fall at
her local mall, where she often walks with friends in the morning. The incident involved an employee at the mall being shot and killed by an abusive
former spouse, who also shot and injured a bystander, before turning the gun on himself, she says. “It was just so random. One minute that man was
shopping at the mall, the next he was in the ICU after some lunatic there to shoot his wife just decided to shoot him too” Soon after, she had her
first panic attack, she reports. She acknowledges her increased anxiety, but “I also think there is something physically wrong with my heart, too. I
just want to stay home so nothing taxes my heart too much. I worry I will drop dead before they figure out what is wrong with me.” LL reports having
the “heart episodes” 2-4 times per week. She also reports generalized worry about “a lot of things”, but notes the episodes can occur even when she is
not feeling anxious, she says. Reliving factors are staying at home, doing yoga in her living room, and talking to friends. She feels worse when she
watches the news, or has to go to the store or public places.
Past Psych Hx: LL denies previous psychiatric diagnosis, medications, or treatment. She denies any previous psychiatric hospitalizations. She reports,
“I have always been ‘high strung’ “. She reports that in the past 20 years, she has had two periods where she was as worried as she is now – age 18 at
college she was “really anxious” about there being a nuclear war, to the point where she had to drop out of a class on history of the Cold War because
the content was making her “think all the time that any minute the missiles were going to start flying”. She reports another episode when her son was a
newborn of losing weight, poor sleep due to worrying that “something bad” would happen to him. Both episodes resolved “eventually” she reports, with no
treatment. She reports friends and family have always teased her about “being neurotic”.
Past Medical Hx: LL reports hypothyroid, dx at age 36, well controlled with Synthroid. LL reports current undiagnosed “heart condition”, evaluated by
her PCP 4 months ago. PCP did cardiac workup, including blood tests for cardiac markers, EKG, and stress test, all were WNL. LL reports PCP told her
heart symptoms “were probably anxiety”, but she says she doubts that diagnosis because “anxiety doesn’t make you almost faint”. She has requested a
referral to a cardiologist, consult pending, she says.
Family/Social Hx: LL is divorced, with two adult sons. She reports she was married at age 22, and the couple divorced 3 years ago, after 23 years of
marriage. She reports a “decent” relationship with her former husband. LL is the youngest of three children. She was raised by both parents, and
reports a “good” childhood. Her mother died from an M.I. at age 53, and her father died from lung cancer at age 72. She reports the rest of her family
is“all healthy”. She is close to her siblings.
Family Psychiatric Hx: LL reports her oldest son takes medication for anxiety, and depression. She reports her father was a “worrier”, but says he
never had any diagnosis or treatment for mental health issues.
Substance Use Hx: Occasional glass of wine, or margarita, no more often than twice a month, and no more than two drinks at a time. Denies current, or
history of tobacco, or illicit substance use.
Review Of Systems: Comprehensive review of systems negative except for loss of appetite increased sweating, and loss of 10 pounds in 4 months.
Physical Exam: BP 150/90, P92, HT 64” WT 122 lbs
Mental Status Exam:
Appearance: LL is dressed neatly in a clean, pressed pantsuit, hygiene and grooming good, appearsyounger than stated age.
Behavior: Psychomotor agitation noted: LL sits on edge of chair, fidgets with hands in lap, and bounces legs. Eye contact is good.
Speech: normal-to- rapid, esp. when describing stressors
Mood: LL reports her mood is “mostly good, I am an upbeat person. But I am worried about what is wrong with me, and it is making me not my normal self.”
Thought Process: Linear, organized, occasionally tangential when describing recent stressors
Thought Content: Logical, no hallucinations or delusional content. Denies suicidal or homicidal ideation.
Cognition: Alert. Recent and remote memory grossly intact. Good awareness of current events. Alert and oriented to all spheres
Case conceptualization (20 points)
Using your Carlat& DSM5 texts and other relevant sources, develop your clinical impression.
1. Create a concept map, table, or decision tree to help you identify all relevant psychiatric and medical conditions you would consider for this
individual. Include the DSM5 criteria for psychiatric diagnoses.
2. From the above, create a prioritized list of your top 3 differential diagnoses, starting with the primary working diagnosis (your answer).
Explain your thinking process on what factors you considered that led you to select your primary diagnosis, and other possible diagnoses.
3. List two most pertinent interview questions for each differential you need to ask to rule in or rule out that diagnosis.
4. List any pertinent laboratory tests or screening tools you might use to help you rule in or rule out your top 3 differential diagnoses and a
concise rationale statement.
For questions 1-4, provide text/reference, page number (in APA style) where you found the information to support your thinking. Use your own words,
limit any direct quotes to no more than 1-2 phrases.
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