AMC Clinical exam preparation

amc clinical exam

Your next patient in the emergency department is a 33 years old Mr. James Strong. The triage nurse noted that he stated “I am loosing it, I am going mad!”. Whilst he was sailing with a navy ship over the last 2 months, he has suffered from repeated episodes of racing of the heart, central chest pains and shortage of breath, often connected with a feeling of doom. He also has had a number of attacks of sweating and trembling. He did not have the courage to report to the ship doctor because being sick is considered as being weak by the navy.
YOUR TASK IS TO:
• Take a further history
• Examine the patient
• Organize appropriate investigations
Discuss your diagnosis and differential diagnosis with the examiner

HOPC: As above. The first episode started about 2 months whilst he was actually resting and lasted for about 10 minutes although he felt it was much longer and since then he had these attacks almost every day, sometimes several times in a day. He could not identify any trigger factors but between the attacks he worries a lot about a new one coming on. He came back to his family in Melbourne a few days ago and he is really concerned about these attacks and now thinking about it almost all the time and it is driving him crazy.
PHx,.+FHx.: unremarkble
SHx: single sailor in the navy, non smoker, occasional alcohol, no illicit drugs, NKA, no medication
EXAMINATION: normal
INVESTIGATIONS: normal

DIAGNOSIS: PANIC DISORDER (PANIC ATTACKS)
A panic attack is the sudden, unexpected onset of a discrete, brief period of intense discomfort, anxiety, or fear accompanied by somatic or cognitive symptoms, usually reaching its peak within 10 minutes. Panic disorder is occurrence of repeated panic attacks typically accompanied by fears about future attacks (anticipatory anxiety) and has at least four of the following symptoms during at least one of the attacks:
• SOMATIC:
o shortness of breath (dyspnoea) or smothering sensations
o dizziness, unsteady feelings or faintness
o palpitations or accelerated heart rate (tachycardia)
o trembling or shaking
o sweating
o choking
o nausea or abdominal distress
o numbness or tingling sensations (paraesthesias)
o flushes (hot flashes) or chills
o chest pain or discomfort
• COGNITIVE:
o depersonalisation (detachment from self) or derealisation (strangeness)
o fear of dying
o fear of losing control or of going crazy or of doing something uncontrolled
The DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDER, 4th edition (DSM-IV) has established the following criteria for panic disorders:
1. recurrent, unexpected panic attacks.
2. Attacks followed by 1 month of one of the following: concerns about having additional attacks, worry about the consequences of attacks, or a change in behavior as a result of attacks.
3. Attacks are not caused by substance abuse, by medication, or by a general medical condition.
4. Attacks are not better accounted for by another mental illness.
5. Can occur with or without agoraphobia (anxiety about being in places or situations from which escape might be difficult or embarrassing).
Panic disorders can be present in many anxiety disorders and often have depression involved as well.
DIFFERENTIAL DIAGNOSES:
• Organic problems simulating a panic attach like hyperthyroidism, AMI, phaeochromocytoma and hypoglycaemia!
• Medications (steroids, anticholinergics, theophylline) and drugs (amphetamines, cocaine, hallucinogens).

MANAGEMENT:
• Reassurance, explanation and support (as for generalised anxiety). This is the mainstay of treatment.
If hyperventilating, breathe in and out of a paper bag.
• Cognitive behaviour therapy (CBT) aims to reduce anxiety by teaching patients how to identify, evaluate, control and modify their negative, fearful thoughts and behaviour. If simple psychotherapy and stress management fails then patients should be referred for this therapy.
Patients' fears, especially if irrational, need to be clearly explained by the therapist, examined rationally and challenged, then replaced by positive calming thoughts.

• Pharmacological treatment:
Acute episodes, i.e the panic attack:
diazepam 5 mg (o) or oxazepam 15-30 mg (o) or alprazolam 0.25-0.5 mg (o)
but only for a short period!
• Selective serotonin re-uptake inhibitors (SSRIs) like paroxetin 20-60 mg (o)