Identification

Full name: K.P
DOB: 1/5/99
Date & Time: 10/23/2022 9:22 AM Location: NYPQH
Religion: Catholic
Source Of Information: Self Language: English
Reliability: Reliable
Mode of Transport: Driven by partner

CC – “Anxiety Attack”

History of Present Illness

23 y/o F with PMH anxiety c/o dull left sided chest pain that radiates to the left arm 1 day ago. Pt rates chest pain 8/10 initially for 30 minutes, and 2/10 during the time of this interview. During onset of symptoms, pt reports numbness of left arm and palpitations that also lasted 30 minutes, which she then notified her partner to drive her to the hospital. Pt has recurrent anxiety attacks about once a week. Last week she woke up from her sleep feeling anxious and short of breath. Last week’s episode resolved on its own in about 10-15 minutes. Last episode similar in severity to today’s visit was 8 years ago. Pt also reported headache during onset of symptoms but it has resolved. Pt’s usual breathing exercises for anxiety did not help. Pt had a therapist 8 years ago but not currently. Pt denies nausea, diaphoresis, vision changes, syncope, wheezing or feelings of hopelessness or helplessness.

Past Medical History

Anxiety – 8 years

Immunizations

COVID – pt received pfizer booster in 2021

Influenza – Last vaccine 1 year ago
Pneumonia – pt has not received pneumonia vaccine

Medications

Denies Medications

Allergies:

No known drug allergies

Family History

Mother: Living, 40 y/o, Hypercholesterolemia Father: Living, 52 y/o, Hypercholesterolemia Grandmother: decreased, reason unknown Grandfather: deceased, reason unknown

Pt denies siblings
Pt does not have children

Social History

1 standard size cocktail every 2 weeks
Recent travel to Dominican Republic 2 weeks ago
Pt notes diet consisted mainly of carbs on vacation. Diet is “healthy” otherwise
Pt is sexually active with 1 male partner. Condoms are used “occasionally”. Pt took plan B contraceptive 1 week ago.
Pt reports 5-6 hours of sleep per night
Pt is a graphic designer – notes work has been stressful recently
Denies illicit drug use
Denies caffeine use
Denies tobacco use
Denies physical activity besides going to work

Review of Systems

General: Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever, chills, or night sweats

Skin, Hair, nails: Pt denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head: Dull, frontal, headache 1 day ago during onset of anxiety symptoms. Pt rates headache 5/10 and notes it subsided on its own. Pt denies radiation of headache to other areas. Currently, pt does not have a headache. Denies vertigo, head trauma, LOC

Eyes: denies visual disturbance, blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, priuitis, last eye exam 2 years ago, pt does not wear glasses.

Ears – denies deafness, pain, discharge, tinnitus, or hearing aids Nose/sinus – denies discharge, epistaxis, obstruction

Mouth and throat: denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures. Pt notes good dental hygiene.

Neck: denies localized swelling/lumps, stiffness/decreased range of motion.

Pulmonary System: Pt notes 4/10 dyspnea last night while trying to sleep that lasted for about 20 minutes. Pt denies alleviating/exacerbating factors but notes she has been stressed from work. Denies cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea.

Cardiovascular System: 8/10 chest pain on arrival, currently 2/10. Left sided chest pain radiating to pt’s left arm. Pt notes palpitations for 30 minutes during onset of chest pain. Denies alleviating/exacerbating factors. Denies HTN, syncope, known heart murmur, edema/swelling of ankles or feet.

Genitourinary System: pt denies frequency, nocturia, urgency, oliguria, polyuria, dysuria, color of urine: yellow, Denies incontinence, awakening at night to urinate or flank pain.

Menstrual: LMP: 10/9/2022, Menstrual Cycle: regular (28-30 days), menarche age:12 Denies postcoital bleeding, vaginal discharge, dyspareunia .

Nervous System: pt denies seizures, headache, LOC, sensory disturbances, ataxia, loss of strength, change in cognition/ mental status/memory, weakness.

Musculoskeletal system: denies muscle/joint pain, deformity or swelling, redness.
Peripheral Vascular System: Denies Intermittent claudication, coldness or tropic changes,

varicose veins, peripheral edema, or color change.

Hematologic system: denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, hx of DVT/pe

Endocrine System: denies polyuria, heat or cold intolerance, goiter, excessive sweating, hirsutism Psychiatric System – anxiety since she was 15 y/o. Pt saw a therapist 8 years ago but has not

followed up since. Pt denies psychiatric medications. Denies OCD, depression/sadness

Physical Examination

Vitals Signs

BP – Right arm – Supine: 120/76 Left arm – .
HR: 80, normal sinus
RR: 18 breaths per minute, unlabored

SpO2 – 98% on room air
Temp: 97.9 F, orally
Height: 63 inches
Weight: Pt cannot recall weight BMI: 25

General: Pt appears in no acute distress. Alert and oriented x 3, Appears stated weight and age, neatly groomed

Head and Hair: The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.

Skin: Skin is warm, dry, and intact without rashes or lesions. Appropriate color for ethnicity.

Eyes: Symmetrical OU, no strabismus, no exophthalmos, sclera is white, cornea clear, and conjunctiva is pink.
Visual Acuity: 20/20 OS, 20/20 OD, 20/20 OU on Snellen chart – non corrected
Visual field: PERRL, EOM

Fundoscopy: Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, or exudates

Ears: – Symmetrical and appropriate in size. No lesions/masses / trauma on external ears.
No discharge / foreign bodies in external auditory canals AU.
TM’s pearly white / intact with light reflex in at 7 o clock position on right, and 5 o clock position on left

Seated: 118/83.

Seated: 127/86

Supine: (124/72)

Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.

Nose – Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.

Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.

Lips – Pink, moist; no cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink; well hydrated. No masses: lesions noted. Non-tender to palpation. No leukoplakia.

Palate – Pink; well hydrated. Palate intact with no lesions; masses; or scars. Non-tender to Palpation; continuity intact.

Teeth – Good dentition / no obvious dental caries noted.
Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge. Non-tender to

palpation.

Tongue – Pink; well papillated; no masses, lesions or deviation. Non-tender to palpation.

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest – Symmetrical, no deformities, no trauma. Respirations unlabored / no Paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation throughout.

Lungs – B/L lungs clear to auscultation. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout.

Abdomen – flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to

palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.

adnexal tenderness or masses noted. Pap smear obtained. No inguinal adenopathy.

Rectal – Recotvaginal wall intact. No external hemorrhoids, skin tages, ulcers, sinus tracts, anal

fissues, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace

brown stool present in vault. FOB negative.

Breast exam: Symmetric, no dimpling, no masses to palpation, nipples to symmertric weithout

discharge or lesions. No axillary nodes palpable

Reflexes

2+ throughout, negative Babinski, no clonus appreciated (If abnormal reflexes present document fully as follows)

Brachioradialis Triceps Biceps Abdominal

RL RL

2+ 2+
2+ 2+
2+ 2+ 2+/2+ 2+/2+

Patellar
Achilles
Babinski
Clonus negative

2+ 2+ 2+ 2+ neg neg

Differential Diagnosis and plan:

Panic Attack – Pt c/o chest pain and palpitations. Pt notes hx of anxiety of attacks and notes work has been more stressful than usual.
Plan: Diagnosis of exclusion: must work up for possible causes of chest pain, palpitations and shortness of breath. Once excluded, pt needs reassurance and education. If needed, can administer 1-2 mg Ativan IV/IM/PO. Advise pt to follow up with therapist or refer to hospital psychologist/psychiatrist.

ACS – Pt c/o left sided chest pain, palpitations and dyspnea.
Plan: EKG, Cardiac biomarkers (Troponin, CK-MB, myoglobin), CBC, CMP, PT/PTT, chest x-ray. If EKG shows ischemic changes, ST elevation, NSTEMI, admit pt for further workup.
ST elevation: Thrombolytics + adjunctive therapies (aspirin, nitroglycerin, O2, Antiplatelets, morphine, beta blockers, statin). Pt may require PCI.
NSTEMI – Dual antiplatelet (aspirin) and antithrombotic (heparin) therapy. Also given adjunctive therapies – Oxygen, nitrates, morphine, beta blockers, blood transfusion if necessary to keep hemoglobin above 10.
Unstable Anginal – Plan similar to NSTEMI

Pericarditis – Pt c/o left sided chest pain, palpitations and dyspnea.
Plan: EKG, Cardiac biomarkers (Troponin, CK-MB, myoglobin), chest x-ray. If EKG shows diffuse ST elevations, this may indicate pericarditis. Prescribe NSAIDS and reassure them that they are not having an MI. Pt may be discharged the same day. If needed, A bedside ultrasound can be done to rule out effusion. CT or cardiac MRI if initial workup is non diagnostic and clinical suspicion persists.

GERD – Pt c/o chest pain radiating to arm and notes she recently had a bad diet while on vacation. Plan: Advise pt to avoid EtOH, caffeine, nicotine, chocolate, fatty foods. Avoid eating within 3 hr before sleep. If necessary, prescribe pt PPI (omeprazole 20-40mg).

Chest trauma – Pt was in car before coming to the hospital. An event may have caused the chest pain such as small accident. This could lead to chest trauma in addition to anxiety.
Plan: Inspection, palpation of chest wall. Chest and rib x-ray. If confirmed, can give morphine for pain and educate patient on extent of injuries.

Due to this patient’s history and presenting symptoms, I’m suspecting an anxiety attack. Considering the pt has been having an anxiety attack once a week, i would refer her to a psychologist. I would also refer her to a psychiatrist and place her on a SSRI (zoloft) or benzodiazepine (Xanax). Pt is advised to follow up with a psychologist and psychiatrist monthly for possible medication adjustment and therapy