Ms. Myers is a 28-year-old woman who is a military spouse. She arrives to the Booking area after a visit to the local emergency department for recurrent episodes of chest pain. At the emergency department, where she had been going for the same complaint about every 3-4 weeks for the last 6 months, staff did a brief examination and discharged her within an hour. She was told “It’s in your head” and not to worry about a heart attack. When she was leaving through the waiting room, she became extremely distraught and, sitting on the floor, refused to leave. The local police were called, and she was arrested and brought to your jail. The emergency department staff believe that Ms. Myers is drug seeking, per the officers who arrested her.
Ms. Myers told you that approximately 1 year ago, she began waking abruptly at night feeling “like I’m going to die,” with shortness of breath, trembling, a racing pulse, and chest discomfort, lasting for 10 to 15 minutes. Her chest discomfort is described as general tightness, without radiation, sweating, or nausea. She stated that the episodes were relieved “a little” by getting out of bed, walking around, and opening a window for fresh air. Ms. Myers could not associate the episodes with any particular condition or activity, but she is upset because she knows that they are occurring more frequently, and even the anticipation that one will occur makes her worried. Ms. Myers informed you that she had been tested for heart problems, lung problems and blood sugar problems, and the emergency doctors and nurses told her nothing was wrong. Ms. Myers also told you that her husband has been deployed in Afghanistan (his missions are secret, but this is where he told her he was “this time”) for about 16 months, and she does not hear from him often because of the nature of his job there. She does think about the danger he is in, and sometimes she can’t get it out of her head. Her family does not live anywhere near her and they don’t communicate often. She shared that she is a waitress and someone at work mentioned that she should try something like a valium or klonopin to help her sleep. She has never used any prescription medication like that.
Correctional Nurse Actions
You obtain a Request of Information for the hospital records from Ms. Myers, and complete your Receiving Screening, which is unremarkable. Ms. Myers has no medical history (other than the episodes previously described), and no allergies. The mental health screening reveals loneliness and anxiety, and no family/friend support system. She denies depression, suicidal ideation and memory problems. She is engaged in the interview, and becomes visibly anxious when discussing her husband. You explain how to access healthcare at the jail, and tell her that you have made a referral for her to see the provider the following day. You ensure that she understands the information, and document all in her health record. You add Ms. Myers to the Provider’s list for the following day.
The following day Ms. Myers is evaluated in Provider Sick Call. At that time:
No known drug allergies; no known food allergies.
Ms. Myers denies taking any prescribed or street drugs. She sometimes does use Tylenol and Ibuprofen for things like headaches and muscle pain. She has tried using Benadryl to help her sleep, but it does not always work.
Review of Systems
Her ROS is negative for fever, night sweats, weight loss, loss of appetite, loss of energy, loss of concentration, lack of or excessive sleep, loss of interest, skipped heart beats, extremity swelling, wheezing, cough, nocturia/orthopnea, and heartburn.
Vitals: T 97.8°F; P 115; R 18; BP 118/76; HT 5’6”, WT 145 lbs, BMI 23.4.
General: Well-developed, well-nourished woman appearing stated age. Cooperative with exam but anxious-appearing at times.
Eyes: PERRLA. Conjunctiva and sclera clear, no injection or exudate.
Neurologic: Cranial nerves II to XII intact. Gait steady. Hand-grasps, pedal pressure bilaterally equal and strong. Deep tendon reflexes intact.
ENT/Mouth: Ear canals clear, TMs pearly gray, intact with normal light reflex. No nasal deformity, pharynx without erythema or exudate.
Neck: No thyromegaly, nodules, bruits, or adenopathy noted.
Heart: S1, S2; RRR; no murmurs, gallops, rubs, or clicks auscultated; Chest non-tender to palpation.
Lungs: Clear to auscultation bilaterally without adventitious sounds; symmetric expansion.
Abdomen: +BS all quadrants, soft, non-tender to palpation; non-distended, no masses, no scars, no hepatomegaly.
Extremities: Pulses 2+ and equal; no tenderness, redness, swelling or varicosities noted.
Psychiatric: Alert and oriented x 4; animated and engaged in the conversation. At times, became tearful. Denies suicidal ideation. Denies depression.
No acute distress, communicates well.
Differential Diagnoses for Ms. Myers
•Variant angina is a diagnosis that matches the patient’s symptom onset and character, but transient EKG changes and cardiac enzyme elevation were not observed in her Emergency Department evaluations.
•Gastroesophageal reflux disease is a possibility, as it can mimic substernal angina pectoris and can awaken a patient from sleep and may be exacerbated by emotional distress. GERD’s key characteristics of quality of pain (burning), duration (minutes to hours), and associated symptoms (nausea, vomiting, dysphagia) were absent in this patient, thereby making this diagnosis less likely.
•Generalized anxiety disorder is on the differential list; however, the patient does not meet the diagnostic criteria for GAD. She does not worry about a number of events or activities; she is unaware of the worry that she tries to control, and of the six symptoms of worry (three of six needed to diagnose) she has only one (sleep disturbance). She is not significantly impaired socially; her symptoms are not related to substance use but do align with another mental health diagnosis, which rules out GAD.
•Depression is an unlikely diagnosis. Her ROS is negative for loss of appetite, loss of energy, loss of concentration, lack of or excessive sleep, or loss of interest, suggesting that she is not depressed.
•Panic disorder/panic attack is a likely diagnosis. Age, history, negative physical findings, and the Emergency Department workups suggest a non-physical cause. The patient has significant risk factors for this diagnosis (military spouse, husband deployed to dangerous area, patient isolated from family).
A metabolic and chemistry panel was ordered, as were thyroid studies. The hospital diagnostic test results were reviewed. Because Ms. Myers was not complaining of any abnormalities at the time of the visit, no EKG was indicated.
The Provider conducted patient education with Ms. Myers to include a brief explanation of panic disorder; the other risks she faces as a military spouse, including other psychiatric disorders and substance use; the benefits of diaphragmatic breathing; techniques of diaphragmatic breathing; and the risks/benefits to using medication like selective serotonin re-uptake inhibitors and benzodiazepines.
Ms. Myers was referred to the mental health clinician for testing to include the PHQ-9 for Depression and the GAD-7 for Generalized Anxiety Disorder. Both were negative. Treatment by the mental health professional included strategies to alleviate panic attacks, such as diaphragmatic breathing techniques, yoga, cognitive behavior therapy and exercise.
Together with Ms. Myers, the decision was made to try the non-medication interventions. Ms. Myers verbalized gratefulness that someone finally “believed her” and that she was not going crazy. She was released two days later.
Prevalence and TReatment Options
U.S. military spouses have a high prevalence of psychiatric morbidity, including depression, anxiety, panic disorder, and substance misuse.
Statistics from the Bureau of Justice indicate that approximately 44% of the jail population and approximately 37% of the prison population have been told they have a psychiatric disorder. Eighteen percent of the jailed population and approximately 12% of the prison population report Anxiety Disorder.
Anxiety disorders are common causes of patient visits to emergency departments. The most common treatment provided during these visits is benzodiazepines, which may offer immediate symptom relief but are potentially dangerous because of risk of overdose and addiction.
Effective stress management techniques for patients include diaphragmatic breathing, yoga, cognitive behavioral therapy, and exercise (among others). Desirable features of self-help techniques include effectiveness, easiness to learn, can be done anywhere, are under patient control, and are at no cost with limited potential for harm.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013.
Bronson, J. & Berzofsky, M. (2017). Special report: Indicators of mental health problems reported by prisoners and jail inmates, 2011-2012. Retrieved from https://www.bjs.gov/content/pub/pdf/imhprpji1112.pdf
Dark T, Flynn HA, Rust G, Kinsell H, Harman JS. Epidemiology of emergency department visits for anxiety in the United States: 2009–2011. Psychiatr Serv. March 1, 2017;68(3):238–244. doi:10.1176/appi.ps.201600148
Graeff FG. Translational approach to the pathophysiology of panic disorder: focus on serotonin and endogenous opioids. Neurosci Biobehav Rev. 2017 May;76 (pt A):48–55. doi:10.1016/j.neubiorev.2016.10.013
Hopper SI, Murray SL, Ferrara LR, Singleton JK. Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: a quantitative systematic review. JBI Database Syst Rev Implement Rep. September 2019;17(9):1855–1876. doi:10.11124/jbisrir-2017-003848
Serenity. The benefits of breath awareness. https://serenityzen.com/blog/2019/1/20/the-benefits-of-breath-awareness. September 28, 2020.
Steenkamp MM, Corry NH, Qian M, et al. Prevalence of psychiatric morbidity in United States military spouses: the Millennium Cohort Family Study. Dep Anxi. September 2018;35(9):815–829. doi:10.1002/da.22768
van Ballegooijen W, Riper H, Klein B, et al. An Internet-based guided self-help intervention for panic symptoms: randomized controlled trial. J Med Internet Res. July 29, 2013;15(7):154. doi:10.2196/jmir.2362 Vorkapic CF, Rangé B. Reducing the symptomatology of panic disorder: the effects of a yoga program alone and in combination with cognitive-behavioral therapy. Front Psychiatry. 2014;5:177. doi:10.3389/fpsyt.2014.00177
Wijesinghe, Sampath. (2021). 101 Primary Care Case Studies: A workbook for clincal and bedside skills. Springer Publishing Company. Kindle edition.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.