Case 49: Monica Middlethorpe

INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history and suggest your management plan to Monica. You are Monica’s usual GP.

The following information is on her medical record:

• Past medical history

• Asthma

• Medication

• Fluticasone/salmeterol 250 mcg/25 mcg per dose (Seretide) inhaler 1 puff twice daily

• Salbutamol 100 mcg/dose (Ventolin) inhaler 2 puffs as required

• Allergies

• Nil

• Immunisations

• Nil recorded

• Family history

• Nil recorded

• Social history

• Administrative assistant (ex-tour guide)

• Non-smoker.

INSTRUCTIONS FOR THE PATIENT, MONICA MIDDLETHORPE

You are 36 years old. You work as an administrative assistant and used to be a tour guide.

You now get anxious when in enclosed spaces. It starts with butterflies in your stomach, then your chest feels tight, your heart races, you feel frightened and you have a strong urge to run out into an open space. You recently flew interstate and your husband was quite upset with you when you almost didn’t get on the plane home. You drank a couple of glasses of wine in the bar before take-off and somehow managed to fly.

You are planning a trip to Europe in six weeks and are worried about the flight. You have come to see your usual GP for help.

If the doctor asks sensitively, you will reveal that three years ago you had an asthma attack when leading a tour group in a cave. You did not have any salbutamol with you and became unwell and anxious. You had to change jobs because it was so awful. Since then you have been afraid of closed spaces and realised, when planning this trip, how much it is affecting your life.

The following information is on your medical record:

• Past medical history

• Asthma

• Medication

• Fluticasone/salmeterol 250 mcg/25 mcg per dose (Seretide) inhaler 1 puff twice daily

• Salbutamol 100 mcg/dose (Ventolin) inhaler 2 puffs as required

• Allergies

• Nil

• Immunisations

• Nil recorded

• Family history

• Nil recorded

• Social history

• Administrative assistant (ex-tour guide)

• Non-smoker.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Explore Monica’s ideas, concerns and expectations.

Assessment of the problem

Ask about recent event on flight

Sensitively probe for possible precipitating event

Explain correlation between significant event and current symptoms

Exclude underlying generalised anxiety or depression or substance misuse.

Management

Psychoeducation and reassurance that help is available

Short term—can use benzodiazepines for specific situations but risk of addiction, not ...