Steven Van Dyke iHuman Case Study

Steven Van Dyke is a 36-year-old Caucasian male smoker who presents to the ED following the acute onset of non-radiating, nonreproducible chest tightness of >20 minutes duration, symptoms beginning while he was watching TV. In this comprehensive guide, we’ll walk you through how to approach his case, from initial history-taking through physical examination to the final diagnosis of panic disorder. You’ll learn the key clinical reasoning steps, what the iHuman grading rubric expects, and a complete step-by-step solution to help you confidently navigate this psychiatric case simulation.

Steven Van Dyke iHuman Case Overview (Doorway Information)

Patient Overview: Steven Van Dyke is a 36-year-old Caucasian male smoker presenting with a chief complaint of “chest tightness” that has been occurring over the past month. He describes experiencing acute onset of nonradiating, nonreproducible chest tightness lasting >20 minutes while watching TV. The current episode is accompanied by palpitations, shortness of breath, choking sensation, dizziness, nausea, sweating, and “fear of having a heart attack.”

Key Background Information:

• Age/Gender: 36-year-old male
• Chief Complaint: Chest tightness >20 minutes duration
• Duration: 1-month history of similar episodes lasting 5-20 minutes
• Current Episode Characteristics: Occurred at rest while watching TV, lasting >20 minutes
• Associated Symptoms: Palpitations, dyspnea, choking sensation, dizziness, nausea, diaphoresis, fear of dying
• Significant History: Childhood asthma, smoker, denies psychiatric history
• Family History: Father died 2 years ago at age 62 due to MI
• Episode Pattern: First episode during exercise, subsequent episodes during work meetings, current episode at rest
• Progression: Episodes increasing in intensity over the past week

The patient appears anxious with fidgeting of hands and legs, is tachycardic, and takes deep breaths between speaking in phrases. The cardiopulmonary and neurologic exams are otherwise normal. His presentation is classic for panic disorder, making this an excellent case for learning systematic psychiatric assessment and differential diagnosis skills.

Steven Van Dyke (36 y/o male) – Chest Tightness Assessment

• CC: Chest tightness >20 minutes duration
• MSAP: Acute onset nonradiating chest tightness while at rest, associated with multiple autonomic symptoms and fear of death
• Associated symptoms: Palpitations, shortness of breath, choking sensation, dizziness, nausea, sweating, fear of having heart attack
• History: Smoker, childhood asthma, family history of MI, denies psychiatric history
• Pattern: Episodes started with exercise, progressed to work-related stress, now occurring at rest

History Questions:

• How can I help you today?
• Tell me more about the chest tightness you’re experiencing
• When did this episode start and what were you doing?
• Have you experienced similar episodes before?
• How long do these episodes typically last?
• What does the chest tightness feel like? (tight, squeezing, pressure, heavy)
• Do you have any allergies?
• Are you taking any medications, including over-the-counter or herbal supplements?
• Do you experience racing heart or irregular heartbeats during these episodes?
• Do you feel short of breath or like you can’t catch your breath?
• Do you experience dizziness, lightheadedness, or feeling faint?
• Do you have nausea or stomach upset during these episodes?
• Do you sweat or feel hot/cold during these episodes?
• Do you feel like you’re choking or have difficulty swallowing?
• Do you have feelings of fear, panic, or feeling like you might die?
• Do you feel like you’re losing control or going crazy during these episodes?
• What triggers these episodes or makes them worse?
• What helps these episodes get better?
• Have you been under increased stress lately?
• Tell me about your work and any recent changes or stressors
• Do you use tobacco products? If so, how much and for how long?
• Do you drink alcohol or use recreational drugs?
• Do you drink caffeine? How much daily?
• Have you had any recent changes in sleep patterns?
• Any family history of heart disease, anxiety, or psychiatric conditions?
• Have you ever been diagnosed with any mental health conditions?
• Have you experienced any recent losses or major life changes?

Physical Exam:

• Vitals: pulse, BP, respirations, temperature, oxygen saturation
• General appearance: anxiety level, fidgeting, speech patterns
• Skin: color, moisture, temperature
• HEENT: pupils, throat examination
• Neck: thyroid examination, lymph nodes
• Chest wall & lungs:
  • Visual inspection of chest wall
  • Palpation for tenderness
  • Auscultation of lungs
• Heart:
  • Auscultate heart sounds
  • Check for murmurs, gallops, rubs
• Abdomen:
  • Auscultation
  • Palpation for tenderness
• Extremities: tremor, edema
• Neurologic: mental status, reflexes

Assessment Note:

S.V.D. is a 36 y/o Caucasian male smoker presenting with 1-month history of episodic chest tightness with associated autonomic symptoms including palpitations, dyspnea, dizziness, nausea, diaphoresis, and intense fear. Current episode occurred at rest while watching TV and has lasted >20 minutes. Episodes began during exercise, progressed to occur during work meetings, and are increasing in frequency and intensity. Physical exam reveals anxious appearance with fidgeting, tachycardia, and rapid breathing, but cardiopulmonary and neurologic exams are otherwise normal. Family history significant for paternal MI at age 62.

Diagnosis: Panic Disorder

Plan:

• Rule out medical causes with appropriate diagnostic testing
• Initiate pharmacological treatment with SSRI (Fluoxetine)
• Short-term anxiolytic therapy (Clonazepam) with planned tapering
• Patient education about panic disorder
• Follow-up care and monitoring
• Consider cognitive behavioral therapy
• Smoking cessation counseling

Steven Van Dyke SOAP Note

Patient: Steven Van Dyke

Subjective Data

CC: 36-year-old male presents with “chest tightness lasting over 20 minutes”

HPI: 36-year-old male presents today with complaints of acute onset chest tightness that began while watching TV and has persisted for over 20 minutes. The patient describes the chest tightness as nonradiating and nonreproducible. He reports associated palpitations, shortness of breath, choking sensation, dizziness, nausea, sweating, and states he has a “fear of having a heart attack.” The patient reports a 1-month history of similar episodes lasting 5-20 minutes that have been increasing in intensity over the past week. The first episode occurred while exercising, with subsequent episodes during work-related meetings. This is the first episode occurring at rest outside of the work setting.

Medications: None currently

Allergies: No known drug allergies

PMH: Childhood asthma. Denies any history of psychiatric disease.

PSH: Denies any surgical procedures

Family History: Father died 2 years ago at age 62 due to myocardial infarction. Denies other significant family history of cardiac or psychiatric conditions.

Social History:

• Tobacco: Current smoker
• Alcohol: Social drinking, denies excessive use
• Illicit drugs: Denies
• Caffeine: Regular coffee consumption
• Occupation: Reports work-related stress

Home environment: Lives independently, reports safe environment

Sleep: Reports difficulty sleeping, particularly after episodes

Exercise: Previously active, now avoiding exercise due to fear of triggering episodes

Objective Data

ROS: General: Reports good health between episodes. Denies fever, chills, or weight changes. Appears anxious and distressed during episodes.

Cardiovascular: Reports palpitations, chest tightness, and fear of heart attack during episodes. Denies chest pain at rest between episodes, syncope, or edema.

Respiratory: Reports shortness of breath and choking sensation during episodes. Denies chronic cough, wheezing, or sputum production.

Gastrointestinal: Reports nausea during episodes. Denies vomiting, abdominal pain, or changes in bowel habits.

Genitourinary: Denies urinary symptoms

Neurologic: Reports dizziness during episodes. Denies headaches, seizures, or weakness.

Psychiatric: Reports intense fear and feeling of losing control during episodes. Denies depression, suicidal ideation, or auditory/visual hallucinations.

Endocrine: Denies heat/cold intolerance, excessive thirst, or frequent urination.

Vital Signs:

• Temperature: 98.6°F
• Pulse: 98 bpm (tachycardic during episode)
• BP: 135/85 mmHg
• Respirations: 20 (rapid during episode)
• SpO2: 98%

Assessment

General: Anxious-appearing young male with fidgeting of hands and legs. Takes deep breaths between speaking in phrases. Alert and oriented x4.

Skin: Warm and dry, no diaphoresis currently noted. Normal color and perfusion.

HEENT: Pupils equal, round, reactive to light. Mucous membranes moist. No thyromegaly.

Cardiovascular: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops, or rubs. No peripheral edema.

Respiratory: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Normal respiratory effort.

Abdomen: Soft, non-tender. Normal bowel sounds. No masses or organomegaly.

Neurologic: Alert and oriented. Cranial nerves intact. No focal neurologic deficits.

Psychiatric: Anxious affect. Thought process linear and goal-directed. No psychosis. Insight and judgment intact.

Differential Diagnoses

Panic Disorder: The patient presents with recurrent, unexpected panic attacks characterized by rapid onset of intense fear with multiple physical and psychological symptoms including palpitations, sweating, trembling, shortness of breath, choking sensation, chest pain, nausea, dizziness, and fear of losing control or dying. Episodes occur without clear triggers and are not caused by substance use or medical conditions.

Acute Coronary Syndrome: While the patient reports chest symptoms, the chest tightness is described as nonradiating and nonreproducible. Symptoms include chest pain, dyspnea, nausea, and diaphoresis. However, the episodic nature, association with psychological symptoms, normal physical exam, and young age make this less likely.

Hyperthyroidism: Could present with palpitations, tachycardia, diaphoresis, tremor, and anxiety. However, the patient lacks classic signs such as heat intolerance, weight loss, goiter, or lid lag.

Substance-Induced Anxiety: Consider caffeine intoxication or withdrawal, stimulant use, or other substances. The patient’s smoking history and caffeine use should be evaluated, but the pattern and presentation are more consistent with panic disorder.

Most Likely Diagnosis: Panic Disorder evidenced by recurrent episodes of intense fear with multiple autonomic symptoms, episodic nature, absence of clear triggers, and normal physical examination.

Plan

Immediate Management:

• Complete medical workup to rule out organic causes
• ECG to evaluate cardiac rhythm and ischemia
• Basic metabolic panel and thyroid function tests
• Reassurance and education about panic disorder

Pharmacological Treatment:

• Initiate Fluoxetine (Prozac) for long-term management
• Short-term Clonazepam (Klonopin) for acute symptom relief with planned tapering
• Patient education regarding medication adherence, side effects, and importance of not stopping abruptly

Non-Pharmacological Interventions:

• Cognitive behavioral therapy, especially if medication unsuccessful during tapering period
• Relaxation techniques and breathing exercises
• Smoking cessation counseling
• Lifestyle modifications including caffeine reduction

Follow-up:

• Reassess at 2 and 10 weeks to discuss effectiveness and assess for side effects
• Continue Fluoxetine for 6 months and consider medication withdrawal with monthly follow-up for relapse
• Return to hospital if continues to experience chest symptoms

Health Promotion:

• Smoking cessation resources and support
• Stress management techniques
• Regular exercise as tolerated
• Sleep hygiene education
• Caffeine reduction

Complete Step-by-Step Guide to Writing the Steven Van Dyke iHuman Case Study

Completing the Steven Van Dyke iHuman case requires a systematic approach that mirrors real psychiatric emergency assessment. This comprehensive guide will walk you through each section of the simulation, providing specific strategies and key points to ensure you achieve the required 70% score.

Step 1: Pre-Case Preparation and Initial Approach

Before diving into the case, take a moment to review the doorway information and formulate your initial clinical approach.

Key Information to Note:

• 36-year-old male with “chest tightness” >20 minutes
• Multiple autonomic symptoms suggesting panic
• Consider both cardiac and psychiatric differentials given age and smoking history

Initial Clinical Mindset: Approach this case with panic disorder as a primary consideration while maintaining awareness that cardiac conditions must be ruled out given the smoking history and family history of MI. The combination of autonomic symptoms with psychological distress strongly suggests a psychiatric etiology.

Step 2: Conducting the History of Present Illness (HPI)

The HPI is crucial for distinguishing panic disorder from cardiac conditions. Use systematic questioning to establish the diagnosis:

Onset and Timing:

• Key findings: Episodes started 1 month ago, initially with exercise
• Current episode: Started while watching TV (at rest)
• Duration: Previous episodes 5-20 minutes, current >20 minutes
• Frequency: Increasing over past week

Character and Quality:

• Chest tightness (not crushing chest pain)
• Nonradiating, nonreproducible
• Associated with fear rather than physical exertion

Associated Symptoms (Critical for Panic Disorder Diagnosis):

• Palpitations and tachycardia
• Shortness of breath and choking sensation
• Dizziness and lightheadedness
• Nausea
• Diaphoresis
• Fear of dying or having heart attack
• Feeling of losing control

Triggers and Pattern:

• Initial trigger: Exercise
• Progression: Work-related meetings (stress)
• Current: At rest (no clear trigger)
• Escalating pattern over past week

Step 3: Review of Systems (ROS)

Conduct a thorough ROS to rule out medical causes and support psychiatric diagnosis:

Cardiovascular:

• Focus on: chest pain patterns, palpitations, syncope
• Key negatives: No chest pain at rest between episodes, no syncope

Psychiatric:

• Anxiety, panic, fear
• Sleep disturbances
• Mood changes
• Rule out: depression, psychosis, substance use

Endocrine:

• Rule out hyperthyroidism: heat intolerance, weight loss, tremor
• Key negatives help differentiate from thyroid disorders

Respiratory:

• Differentiate from asthma exacerbation
• Focus on: episode-related vs. chronic symptoms

Step 4: Past Medical, Social, and Family History

Past Medical History:

• Childhood asthma (relevant but not active)
• Importantly: Denies psychiatric history
• No previous cardiac events

Family History:

• Critical finding: Father died of MI at age 62
• This increases cardiac risk but also can contribute to health anxiety

Social History:

• Smoking history (cardiac risk factor)
• Work stress (triggers episodes)
• Caffeine use (potential trigger)
• Substance use assessment

Step 5: Physical Examination Strategy

Perform a focused exam that evaluates both cardiac and psychiatric presentations:

Vital Signs:

• Expected: Tachycardia during episodes, elevated BP
• Normal between episodes

General Appearance:

• Key finding: Anxious appearance with fidgeting
• Speech pattern: Rapid breathing between phrases
• Behavior: Restless, fearful

Cardiovascular Examination:

• Normal heart sounds (rules out structural disease)
• Regular rhythm (during examination)
• No murmurs or gallops

Respiratory Examination:

• Clear lung fields (rules out pulmonary causes)
• No wheezing (differentiates from asthma)

Neurologic Examination:

• Normal (rules out neurologic causes)
• Mental status: Anxious but oriented

Step 6: Developing Differential Diagnoses

Propose appropriate differentials with clear rationales:

Primary Consideration: Panic Disorder

• Supporting evidence: Episodic nature, multiple autonomic symptoms, fear of dying, normal physical exam
• DSM-5 criteria: Recurrent unexpected panic attacks with 4+ symptoms

Secondary Considerations:

Acute Coronary Syndrome

• Consider due to: Family history, smoking, chest symptoms
• Arguments against: Young age, episodic nature, normal exam, psychological symptoms predominate

Hyperthyroidism

• Consider due to: Palpitations, anxiety, tachycardia
• Arguments against: No heat intolerance, weight loss, or goiter

Substance-Induced Anxiety

• Consider: Caffeine intoxication, stimulant use
• Evaluate: Caffeine intake, substance use history

Step 7: Diagnostic Test Interpretation

Order and interpret appropriate tests:

Essential Tests:

• ECG: Should be normal or show sinus tachycardia only
• Basic metabolic panel: Rule out electrolyte abnormalities
• Thyroid function tests: Rule out hyperthyroidism
• Consider: Toxicology screen if substance use suspected

Expected Results:

• Normal ECG (rules out cardiac ischemia)
• Normal thyroid function (rules out hyperthyroidism)
• Normal electrolytes

Step 8: Final Diagnosis and MSAP

Primary Diagnosis: Panic Disorder

Justification:

• Meets DSM-5 criteria for panic disorder
• Recurrent unexpected panic attacks
• Multiple autonomic and psychological symptoms
• Fear of dying during episodes
• Normal physical examination
• Functional impairment (avoiding exercise, work stress)

MSAP Selection: Choose “Panic Disorder” as your Most Significant Active Problem.

Step 9: Comprehensive Management Plan

Develop evidence-based treatment approach:

Immediate Management:

• Reassurance and education about panic disorder
• Rule out medical causes with appropriate testing
• Crisis intervention if needed

Pharmacological Treatment:

• First-line: SSRI (Fluoxetine) for long-term management
• Short-term: Benzodiazepine (Clonazepam) for acute relief
• Education about medication timeline and adherence

Psychosocial Interventions:

• Cognitive behavioral therapy (first-line psychotherapy)
• Relaxation techniques and breathing exercises
• Psychoeducation about panic disorder

Lifestyle Modifications:

• Smoking cessation program
• Caffeine reduction
• Stress management techniques
• Regular exercise as tolerated
• Sleep hygiene

Follow-up Plan:

• Short-term: 2-week follow-up for medication tolerance
• Medium-term: 10-week assessment for effectiveness
• Long-term: 6-month treatment course with relapse monitoring

Step 10: Documentation and Submission Tips

Writing Your Summary:

• Create a concise summary explaining your clinical reasoning
• Include how you differentiated panic disorder from cardiac conditions
• Cite specific symptoms that meet panic disorder criteria
• Use professional psychiatric terminology

Key Documentation Elements:

• Assessment: Brief patient summary with key symptoms
• Clinical Reasoning: Explain how you ruled out medical causes
• Evidence Correlation: Link symptoms to panic disorder criteria
• Treatment Rationale: Justify medication choices and therapy recommendations

Final Submission Checklist:

• ✓ Complete psychiatric history with panic symptoms
• ✓ Appropriate physical exam ruling out medical causes
• ✓ Differential diagnoses with clear rationales
• ✓ Correct panic disorder diagnosis and MSAP
• ✓ Evidence-based treatment plan including medication and therapy
• ✓ Professional documentation with psychiatric terminology

Steven Van Dyke iHuman Case Summary

Grading Criteria:

The Steven Van Dyke iHuman case evaluates your ability to diagnose and manage psychiatric emergencies in the ED setting. Here’s what you need to focus on to maximize your score:

(1) History Taking (Major Points): You must ask targeted questions about panic symptoms to get full credit. Essential questions include: chest tightness character, associated autonomic symptoms (palpitations, dyspnea, dizziness, nausea, diaphoresis), psychological symptoms (fear of dying, losing control), episode triggers, duration and frequency, and family psychiatric history. Don’t miss asking about: substance use (caffeine, tobacco, alcohol), work stress, sleep patterns, and previous episodes.

(2) Physical Examination (High Weight): Focus your exam on ruling out medical causes while documenting psychiatric findings. Must-do components: vital signs (noting tachycardia), cardiac auscultation, lung examination, neurologic assessment, and mental status exam. Pro tip: The rubric awards points for documenting anxiety-related findings like fidgeting, rapid speech, and restless behavior.

(3) Differential Diagnosis (Critical for Scoring): You need at least 3 appropriate differentials with rationales. Expected differentials: panic disorder, acute coronary syndrome, hyperthyroidism, and substance-induced anxiety. Scoring secret: The rubric rewards students who can clearly differentiate panic disorder from medical conditions using symptom patterns and normal physical exam findings.

(4) Final Diagnosis & MSAP: You must correctly identify panic disorder as your primary diagnosis. Justification should cite: episodic nature, multiple autonomic symptoms, fear of dying, normal physical exam, and absence of medical causes.

(5) Management Plan (Heavily Weighted): The rubric expects comprehensive psychiatric treatment including: medication management (SSRI and short-term anxiolytic), psychotherapy referral (CBT), lifestyle modifications, and appropriate follow-up. High-scoring responses mention: patient education about panic disorder, medication adherence counseling, and crisis intervention planning.

(6) Patient Communication: Demonstrate empathy and provide clear explanations about psychiatric conditions. Bonus points for: discussing panic disorder psychoeducation, explaining treatment options, and addressing fears about cardiac conditions.

Example of a High-Scoring Clinical Summary

Here’s how a top-performing student might document this case:

Patient Summary – Steven Van Dyke

Situation: 36-year-old male presenting with acute chest tightness and multiple autonomic symptoms consistent with panic attack.

Background: One-month history of episodic symptoms initially triggered by exercise, progressing to work-related stress, now occurring at rest. Significant smoking history and family history of MI create cardiac risk factors but clinical presentation more consistent with psychiatric etiology.

Assessment: Physical examination notable for anxiety-related findings including fidgeting, tachycardia, and rapid breathing, but cardiovascular and neurologic exams normal. Symptoms meet DSM-5 criteria for panic disorder with recurrent unexpected panic attacks including >4 autonomic symptoms and fear of dying.

Primary Diagnosis: Panic Disorder

Recommendation:

• Rule out medical causes with ECG, basic metabolic panel, and thyroid function tests
• Initiate pharmacological treatment with Fluoxetine (SSRI) for long-term management
• Short-term Clonazepam for acute symptom relief with planned tapering schedule
• Cognitive behavioral therapy referral for evidence-based psychotherapy
• Lifestyle modifications: smoking cessation, caffeine reduction, stress management
• Follow-up at 2 and 10 weeks to assess medication effectiveness and side effects
• Patient education about panic disorder, including reassurance about medical safety

Patient Education Provided: Explained panic disorder pathophysiology, differentiated from cardiac conditions, emphasized treatability with medication and therapy, provided crisis intervention plan for future episodes, and addressed smoking cessation for overall health.

Conclusion

By following this comprehensive approach to the Steven Van Dyke case, you’ll demonstrate the clinical reasoning skills that iHuman evaluates for psychiatric presentations. Remember, success in psychiatric cases requires systematic thinking: gather detailed symptom history, perform focused physical examination to rule out medical causes, consider appropriate differentials, and develop evidence-based treatment plans. The key is treating each iHuman simulation as you would a real psychiatric emergency – be thorough, think critically, and always prioritize patient safety while addressing psychological distress. With this guide, you’re well-prepared to excel in this challenging but essential case simulation.

Frequently Asked Questions

Q1: What is the correct diagnosis for Steven Van Dyke’s chest tightness?

Steven Van Dyke’s primary diagnosis is panic disorder. The key distinguishing features include recurrent unexpected panic attacks with multiple autonomic symptoms (palpitations, dyspnea, diaphoresis, nausea), psychological symptoms (fear of dying), episodic nature lasting 5-20 minutes, and normal physical examination. Students often struggle between panic disorder and cardiac conditions, but remember that panic disorder presents with episodic symptoms, multiple autonomic and psychological features, and normal cardiac examination.

Q2: What are the critical history questions I need to ask to score well?

Essential history elements include asking about the character of chest tightness (tight vs. crushing), associated autonomic symptoms (palpitations, shortness of breath, dizziness, nausea, sweating), psychological symptoms (fear of dying, losing control), episode triggers and patterns, duration and frequency, family history of cardiac and psychiatric conditions, substance use (especially caffeine and tobacco), work stress, and sleep patterns. Many students miss points by not exploring the psychological component of symptoms or failing to ask about episode triggers and patterns.

Q3: How do I differentiate panic disorder from cardiac conditions in this case?

Key differentiating factors include:

1) Episodic nature with complete resolution between episodes (vs. progressive cardiac symptoms),

2) Multiple autonomic symptoms occurring together (vs. isolated chest pain),

3) Prominent psychological symptoms like fear of dying (uncommon in cardiac events),

4) Normal physical examination including cardiac auscultation,

5) Young age despite smoking history,

6) Association with stress rather than physical exertion, and

7) Nonradiating, nonreproducible chest tightness (vs. classic cardiac pain patterns).

Q4: What management interventions should I include for panic disorder?

Comprehensive management should include: immediate reassurance and psychoeducation about panic disorder, medical workup to rule out organic causes (ECG, basic metabolic panel, thyroid function), pharmacological treatment with SSRI (Fluoxetine) for long-term management and short-term anxiolytic (Clonazepam) with tapering plan, psychotherapy referral for cognitive behavioral therapy, lifestyle modifications including smoking cessation and caffeine reduction, stress management techniques, and structured follow-up at 2 and 10 weeks. Students often forget the importance of patient education and psychotherapy referral, which are crucial components for comprehensive psychiatric care.