In the next in our series, Dr Peter Bagshaw describes an unusual case of a female patient who initially presented with panic episodes
Note details of this case have been changed to protect individuals’ identities
A 52-year-old year old female patient presented with a recent history of panic episodes. In particular, these came over her when driving, and she would have to pull over to recover. There was a history of mild OCD but no other significant medical history.
On direct questioning she admitted insomnia but no other symptoms, although, oddly, she volunteered that she had developed a craving for pears; the GP found she was going through a very difficult time with a divorce and moving house. On examination they noted mild tachycardia but nil else.
The patient was prescribed citalopram and referred for CBT; she returned six weeks later saying she felt a little worse, and was now struggling to work. The tachycardia was more troublesome, so she was signed off work and an ECG was arranged. This confirmed sinus tachycardia, for which she was prescribed low-dose bisoprolol.
A month later, she returned feeling much worse.
What would you do next, and what might it show?
Put your suggestions in comments below. Answer to be revealed soon!
Dr Peter Bagshaw is a GP and mental health lead at Somerset ICB
Obviously this is a well-read and sensible and rational lady, but she is panicking because driving behaviour has so deteriorated since the Pandemic started she is scared by the other drivers around her. It is exacerbated by announcements that Mr Trump wants to invade Palestine, Greenland, Canada, Korea, Russia, Ukraine, parts of Africa and South America and impose US laws on them, and probably GB too, why not? And this is a very scary thought, so I would send a blood sample for Thyroid tests and encourage her to campaign to exclude USA from ability to interfere elsewhere.
Agree David, a blood test for thyroid function. Why is it when somebody says they have domestic issues they immediately get placed on those toxic SSRI’s.? Modern day Librium. I’ll get my coat.
Well assuming this is not just anxiety/life/OCD or world events (as meds and counselling should have eased things a bit by now) and assuming a challenge for a hidden agenda, I would definitely have wanted a TFT/FBC/UE/bond profile etc by now and would also consider a 24hr VMA for rarities. May be try higher BB eg propranolol 80mg LA for somatic aspects and maybe higher ssri or swap to sertraline . Make sure you give patient time to review what’s really bothering her and if she agrees to a further Period on higher meds and other tests. Possible fit note
Well assuming this is not just anxiety/life/OCD or world events (as meds and counselling should have eased things a bit by now) and assuming a challenge for a hidden agenda, I would definitely have wanted a TFT/FBC/UE/bond profile etc by now and would also consider a 24hr VMA for rarities. May be try higher BB eg propranolol 80mg LA for somatic aspects and maybe higher ssri or swap to sertraline . Make sure you give patient time to review what’s really bothering her and if she agrees to a further Period on higher meds and other tests. Possible fit note , ask a colleague over coffee!
Pheochromocytoma
Stop B blocker IMMEDIATELY and do bloods for TFT AND 24 HR urine Catecholamines (B blocker could kill her if it’s a Phaeo)
Pears are high in copper relative to other fruits/foods – was her body craving copper? when she was driving, she wasn’t able to eat pears which exacerbated her symptoms. Copper deficiency can be caused by excessive use of zinc supplements and also liver cirrhosis. Copper deficiency can cause the symptoms noted, including thyroid problems and visual problems (perhaps she couldn’t see so well when driving?). SSRIs should be used in caution with liver disease and with undiagnosed cardiac arrhythmias as incorrect prescribing can worsen these symptoms (as it did in this case). Or perhaps she just likes pears…. Please do a case study on hypophosphatemia related to Ferrinject (iron infusion) – it is very, very difficult to treat and is often fobbed off as post-infusion ‘flu’