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You are an FY1 working at a GP surgery. Your next patient is 35-year-old Jess Tation, who has come in today as she feels like she is ‘going crazy’. Please take a history from Jess, ensuring to elicit her concerns about her symptoms, and perform a relevant examination.

HPC: It started three months ago with you starting to feel a bit tense and worried about small silly things, like going to work or taking your children to school; you’d feel like something bad was going to happen. At first you thought it was just a phase and it would pass, and you managed to carry on through the episodes. However over the last month in particular, it’s got a whole lot worse. You get worried about doing almost anything. On leaving the house, you’re worried you’ll come to harm in some way. On making dinner, you’re scared that your oven will explode and you haven’t used the oven in days. You’re terrified that your children will get abducted if you let them play outside, even in your own fenced garden. And these are just a few examples.

You work part time as a secretary at a law firm, and you’re still able to get to work on the three working days that you do, but once you get there, you find it very difficult to concentrate. In fact, the last week, you haven’t been in at all because you feel like something awful will happen en route to work. For the last two weeks, your neighbour has been picking your girls up from school, as you told them that your work schedule had been changed to get out of having to leave the house.

You’ve also started feeling physically sick. Over the last month, your heart has began to race and you get these awful chest pains, and you start feeling really hot and sweaty. This happens before you leave the house, or when you know your children are going to be leaving the house, although now you feel like that a lot of the time.

Now, you get these “crazy episodes” as you call them, on most days.

You don’t feel low in mood as such, but these episodes are starting to get you down, and you feel guilty about the impact the condition is having on your daughters. You’ve never felt overly high in mood, and you’ve never thought about harming yourself during these episodes, or harming anybody else. You don’t ever feel like you need to act on your thoughts to relieve the anxiety.

ICE: You have no idea what is happening to you, but you hate feeling like this. You feel like you’re going crazy and are worried about what people might think if you tell them how you feel. Coming today was a big deal for you, and you’ve come because you feel like you’re letting your girls down by not picking them up from school, not working, and refusing to cook them food in the oven or let them play in the garden. You haven’t told your husband as you’re scared he’ll think you’re a nutter. You don’t expect that the doctors will be able to do anything- in fact, you’re expecting a few raised eyebrows and to be sent back out the door. You’re worried that you’ll feel like this forever. You can’t think of anything that specifically triggered the episodes, although work has been a lot more stressful lately.

PMH: You don’t have any history of heart problems, thyroid problems, or breathing problems.

DH: None No allergies

FH: Your dad had a heart attack last year- he is in his 70s. You’re worried your fast heart and chest pain might be something bad with your heart going on.

SH: You live in a semi-detached house in a really nice area with your husband Dick and children Eva, age 9 and Imogen, age 6. Dick works for an oil company and often has to work away for a week or two at a time. Three months ago he went away for four weeks, the longest time you’ve been apart, which was scary for you as you felt like you were responsible for the girls on your own.

You work as a secretary for a law firm, which is about 20 minutes away by car. You work part time in order to be able to watch your girls grow up, and to be there when their father is away. However there’s been some changes at work and you’re finding it hard to adjust to new management. You have friends locally who are very supportive, and would probably be supportive of this situation but you haven’t told them yet.

You don’t smoke, and you occasionally drink a glass of wine when out for a meal. Your alcohol consumption hasn’t changed with the episodes.

Students should be able to elicit the psychological symptoms, and additional biological symptoms that Jess is experiencing, and the effect that these symptoms are having on her life. Students should be able to explore Jess’s concerns about what she thinks may be causing the problems. Students should ask about Jess’ risk of self-harm and of harming others. An appropriate examination would be an MSE.

Differential Diagnosis:

My differential diagnosis would be a psychiatric diagnosis, more specifically an anxiety disorder, as Jess experiences both physical and psychological symptoms associated with anxiety. As Jess experiences symptoms in a variety of situations, a situational cause or phobia is less likely. Combined with the fact that she experiences symptoms on most days, this could indicate generalised anxiety disorder. Jess does not describe any obsessive thoughts, or compulsive actions indicating obsessive-compulsive Disorder is less likely.

Discussion Points:

What physical symptoms can people with anxiety disorders exhibit? What is generalised anxiety disorder? How is this different to other forms of anxiety disorder? How could you go about assessing Jess further? What are the options for managing Jess’ symptoms?