Anna Sink is a 32-year-old schoolteacher who presents at the emergency room with complaints of chest tightness, palpitations, and shortness of breath. Such symptoms arose when she was told that there was a change in her travel schedule because of a change in weather conditions. In this comprehensive guide, we’ll walk you through how to approach her case, from initial history-taking through mental status examination to the final diagnosis of generalized anxiety 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 mental health case simulation.
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Anna Sink iHuman Case Overview (Doorway Information)
Patient Overview: Anna Sink is a 32-year-old Caucasian female presenting with a chief complaint of “chest tightness, palpitations, and shortness of breath” that occurred when she was informed about changes to her travel schedule due to weather conditions. She describes experiencing severe anxiety symptoms including hyperventilation and reports “I am gasping for air” and “Something bad is going to happen.” Her anxiety symptoms were somewhat relieved by the administration of 2 mg Lorazepam orally in the ER.
Key Background Information:
- Age/Gender: 32-year-old female
- Occupation: Schoolteacher
- Chief Complaint: Chest tightness, palpitations, and shortness of breath
- Trigger: News of travel schedule changes due to weather
- Associated Symptoms: Hyperventilation, fear of impending doom
- Duration Pattern: Recurrent episodes occurring 1-2 times per week for the last 6 months
- Previous Treatment: “Off and on” treatment for approximately 3 months with unclear effectiveness
- Current Presentation: Alert and oriented, currently responding to Lorazepam
- Associated Features: Deep-seated fear of impending disaster and difficulty focusing
The patient appears alert, oriented, and cognitively intact, with appropriate insight into her condition. Despite this, her anxiety was persistent and severe, significantly affecting her daily functioning. The GAD-7 assessment tool indicated moderate anxiety, with symptoms such as difficulty controlling worry and feeling on edge. Her presentation is classic for anxiety-related symptoms, making this an excellent case for learning systematic mental health assessment and differential diagnosis skills.
Anna Sink (32 y/o female) – Anxiety Symptoms Assessment
- CC: Chest tightness, palpitations, and shortness of breath
- MSAP: Anxiety-induced physical symptoms triggered by schedule changes, with fear of impending doom
- Associated symptoms: Hyperventilation, difficulty controlling worry, feeling on edge
- History: Recurrent anxiety episodes, previous inconsistent treatment
- Triggering situation: News of travel schedule changes due to weather conditions
History Questions:
Initial Assessment:
- How can I help you today?
- What brought you to the emergency department?
- Can you tell me more about these symptoms you’re experiencing?
- When did these symptoms start today?
- Have you experienced symptoms like this before?
Anxiety-Specific Questions:
- What does the chest tightness feel like? (pressure, squeezing, burning, stabbing)
- How severe are your symptoms on a scale of 1-10?
- What thoughts were going through your mind when this started?
- Do you feel like something bad is going to happen?
- Are you having trouble catching your breath?
- Do you feel like your heart is racing or beating irregularly?
Pattern and Triggers:
- How often do these episodes occur?
- What typically triggers these symptoms?
- How long do these episodes usually last?
- What makes the symptoms better or worse?
- Have you noticed any patterns to when they occur?
- Do certain situations or thoughts bring on these feelings?
Associated Symptoms:
- Do you experience: sweating, trembling, dizziness, nausea?
- Have you had any thoughts of hurting yourself or others?
- Do you feel detached from reality during these episodes?
- Are you having trouble sleeping?
- Have you noticed changes in your appetite?
- Do you feel restless or on edge most days?
Social and Functional Impact:
- How are these symptoms affecting your work as a teacher?
- Are your relationships being impacted?
- Have you had to avoid certain activities or situations?
- Are you able to perform your daily activities normally?
Treatment History:
- Have you sought treatment for anxiety before?
- What treatments have you tried?
- Are you currently taking any medications for anxiety?
- Have you tried counseling or therapy?
- What coping strategies do you typically use?
Physical Exam:
Vital Signs:
- Pulse, blood pressure, respirations, temperature, oxygen saturation
- Note: May show tachycardia, elevated BP, tachypnea during acute episodes
General Appearance:
- Level of distress, posture, eye contact
- Signs of anxiety: fidgeting, restlessness, hypervigilance
Mental Status Examination:
- Appearance and behavior
- Speech patterns and rate
- Mood and affect assessment
- Thought process and content
- Perception (hallucinations/delusions)
- Cognition and insight
- Judgment and risk assessment
Cardiovascular System:
- Auscultate heart for rhythm and murmurs
- Check for signs of heart failure
- Assess peripheral circulation
Respiratory System:
- Assess breathing pattern
- Auscultate lungs for abnormal sounds
- Check for signs of hyperventilation
Neurological Assessment:
- Orientation to person, place, time
- Cognitive function
- Motor function and reflexes
Assessment Note:
A.S. is a 32-year-old Caucasian female schoolteacher presenting with acute onset of chest tightness, palpitations, and shortness of breath triggered by news of travel schedule changes. She has a 6-month history of recurrent anxiety episodes occurring 1-2 times per week, often accompanied by fear of impending disaster and difficulty focusing. Physical examination reveals she is alert, oriented, and cognitively intact with appropriate insight into her condition. GAD-7 assessment indicates moderate anxiety with persistent worry and difficulty controlling anxious thoughts. Her usual coping mechanisms, such as deep breathing exercises, were ineffective during this episode. Symptoms partially relieved with 2mg Lorazepam PO in ED.
Anxiety Assessment: GAD-7 score suggests moderate generalized anxiety disorder with significant functional impairment
Diagnosis: Generalized Anxiety Disorder (GAD)
Plan:
Immediate Management:
- Continue monitoring in ED with vital sign checks
- Assess response to Lorazepam
- Safety evaluation and risk assessment
- Consider additional anxiolytic if needed
Long-term Treatment Plan:
- Pharmacological: Initiate SSRI therapy (sertraline 25mg daily, titrate as needed)
- Non-pharmacological: Referral for cognitive behavioral therapy (CBT)
- Lifestyle interventions: Stress management techniques, regular exercise, sleep hygiene
- Follow-up: Primary care provider in 1-2 weeks, mental health referral within 1 week
Patient Education:
- Provide information about anxiety disorders and treatment options
- Teach breathing techniques and grounding exercises
- Discuss lifestyle modifications
- Provide crisis resources and when to seek immediate help
Anna Sink SOAP Note
Patient: Anna Sink
Subjective Data
CC: 32-year-old female presents with “chest tightness, palpitations, and shortness of breath”
HPI: 32-year-old female schoolteacher presents today with acute onset of chest tightness, palpitations, and shortness of breath that began when she was informed of changes to her travel schedule due to weather conditions. Patient states “I am gasping for air” and “Something bad is going to happen.” She reports a 6-month history of similar episodes occurring 1-2 times per week, often accompanied by intense fear of impending disaster and difficulty concentrating. Patient has been receiving “off and on” treatment for approximately 3 months with unclear effectiveness. Reports that her usual coping mechanisms, such as deep breathing exercises, were ineffective during this current episode.
Medications: Previously prescribed medications for anxiety (specific medications unclear due to inconsistent treatment)
Allergies: No known drug allergies (NKDA)
PMH: Generalized anxiety disorder symptoms with moderate severity on GAD-7 assessment
PSH: Denies surgical history
Sexual History: Deferred for this exam
Hospitalizations: Current ED visit for anxiety symptoms
Health Maintenance: Inconsistent with mental health care over past 3 months
Family History: Family history of mental health conditions (details to be obtained)
Substances:
- Tobacco: Denies current use
- Alcohol: Social use, denies excessive consumption
- Caffeine: Reports moderate intake, may worsen anxiety symptoms
- Illicit drugs: Denies use
Home Environment: Lives independently, reports generally safe environment
Employment: Works as a schoolteacher, high-stress environment
Sleep: Reports difficulty sleeping related to anxiety and worry
Exercise: Variable due to anxiety symptoms affecting motivation
Safety: Reports feeling safe physically but anxious about future events
Objective Data
ROS:
General: Alert, oriented, and cognitively intact female appearing anxious but cooperative. Reports difficulty controlling worry and persistent feelings of being on edge. Denies fever, chills, or weight changes.
Psychiatric: Reports persistent worry, fear of impending doom, restlessness, and difficulty concentrating. GAD-7 assessment tool indicated moderate anxiety.
Cardiovascular: Reports palpitations and chest tightness during anxiety episodes. Denies chest pain at rest, syncope, or orthopnea.
Respiratory: Reports shortness of breath and hyperventilation during anxiety episodes. Denies chronic cough or wheezing.
Gastrointestinal: May report nausea during anxiety episodes. Denies chronic abdominal pain or changes in bowel habits.
Neurological: Reports difficulty concentrating and focusing. Denies headaches, seizures, or weakness.
Vital Signs:
- Temperature: 98.6°F
- Pulse: 98-110 bpm (may be elevated during anxiety)
- BP: 135/85 (may be elevated during anxiety)
- Respirations: 20-24 (may show mild tachypnea)
- SpO2: 98-99% on room air
Physical Assessment:
General: Alert, oriented young adult female appearing mildly anxious but cooperative. Appropriate eye contact and speech. No acute distress following Lorazepam administration.
Mental Status Exam:
- Appearance: Well-groomed, appropriate dress, appears stated age
- Behavior: Cooperative, some fidgeting noted initially
- Speech: Clear, normal rate and tone
- Mood: “Anxious and worried”
- Affect: Anxious, congruent with mood
- Thought Process: Linear and goal-directed
- Thought Content: Worried about future events, no suicidal/homicidal ideation
- Perception: No hallucinations reported
- Cognition: Alert and oriented x3, intact memory and concentration when not anxious
- Insight: Appropriate insight into her condition
- Judgment: Good
Cardiovascular: Regular heart rate and rhythm following treatment, no murmurs appreciated. No peripheral edema.
Respiratory: Clear lung sounds bilaterally, no wheeze or rales. Respiratory pattern normalized following treatment.
Neurological: Cranial nerves intact, normal reflexes, no focal deficits noted.
Differential Diagnoses
Generalized Anxiety Disorder: Patient presents with recurrent episodes of anxiety occurring 1-2 times per week for 6 months, accompanied by physical symptoms and fear of impending disaster. GAD-7 assessment indicates moderate anxiety with significant functional impairment. Symptoms are consistent with DSM-5 criteria for GAD.
Panic Disorder: Patient’s acute episodes with physical symptoms could suggest panic attacks. However, the chronic nature and specific triggers make GAD more likely.
Adjustment Disorder with Anxiety: Patient’s symptoms are related to stressors (schedule changes), but the 6-month duration and frequency suggest a more persistent anxiety disorder.
Medical Causes (ruled out): Hyperthyroidism, cardiac arrhythmias, or other medical conditions causing anxiety-like symptoms should be considered but physical exam and response to anxiolytic suggest primary anxiety disorder.
Most Likely Diagnosis: Generalized Anxiety Disorder evidenced by recurrent anxiety episodes with physical symptoms, fear of impending disaster, difficulty focusing, and significant functional impairment. Patient demonstrates appropriate insight into condition with moderate severity on standardized assessment.
Plan
Health Promotion:
✓ Mental Health Screening: Regular assessment with GAD-7 or other validated tools
✓ Stress Management: Education about stress reduction techniques
✓ Lifestyle Modifications: Regular exercise, adequate sleep, caffeine reduction
✓ Support System: Encourage connection with family, friends, and support groups
Treatment Plan:
✓ Pharmacotherapy: Consider SSRI initiation (sertraline 25mg daily, increase as tolerated)
✓ Psychotherapy: Referral for cognitive behavioral therapy (CBT) ✓ Crisis Management: Provide emergency contact numbers and crisis resources
✓ Follow-up: Primary care in 1-2 weeks, mental health referral within 1 week
Patient Education:
✓ Anxiety Education: Provide information about GAD and treatment options
✓ Coping Strategies: Teach grounding techniques and breathing exercises
✓ Warning Signs: When to seek immediate medical attention
✓ Medication Compliance: Importance of consistent treatment
Complete Step-by-Step Guide to Writing the Anna Sink iHuman Case Study
Completing the Anna Sink iHuman case requires a systematic approach that mirrors real mental health clinical practice. 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:
- 32-year-old female with anxiety-related physical symptoms
- Triggered by schedule changes – identify stressor patterns
- Consider mental health as primary focus with medical rule-outs
Initial Clinical Mindset: Approach this case with anxiety disorders as your primary consideration. The age, presentation, and triggering event immediately suggest generalized anxiety disorder or panic disorder, making this a high-priority mental health assessment requiring systematic evaluation.
Step 2: Conducting the History of Present Illness (HPI)
The HPI is crucial for establishing the foundation of your mental health diagnosis. Use a modified OLDCARTS approach adapted for anxiety:
Onset: Ask about when the current episode started and triggers
- Key points to elicit: Started when informed of travel schedule changes due to weather
Location: Determine physical symptoms and their distribution
- Target response: Chest tightness, palpitations affecting breathing
Duration: How long do episodes last and overall pattern
- Important detail: Episodes occur 1-2 times weekly for 6 months
Character: Detailed description of anxiety symptoms
- Critical descriptors: “Gasping for air,” “something bad is going to happen”
Aggravating factors: What makes anxiety worse
- Essential findings: Schedule changes, unpredictable events, stressors
Relieving factors: What provides relief
- Key response: Lorazepam provided relief, previous coping mechanisms ineffective
Timing: Pattern of symptoms and frequency
- Important pattern: Recurrent episodes with increasing frequency
Severity: Impact on functioning and quality of life
- Significant functional impairment affecting work and relationships
Associated Symptoms:
- Ask specifically about: hyperventilation, trembling, sweating, nausea, dizziness
- Key finding: Fear of impending doom, difficulty concentrating
Step 3: Mental Status Examination (MSE)
Conduct a thorough mental status exam, the cornerstone of psychiatric assessment:
Appearance:
- Grooming, dress, apparent age
- Level of distress, posture, eye contact
Behavior:
- Psychomotor activity (agitation, restlessness)
- Cooperation level, rapport building
Speech:
- Rate, volume, tone, fluency
- Any pressure of speech or speech poverty
Mood and Affect:
- Patient’s subjective emotional state
- Observer’s assessment of emotional expression
- Congruence between mood and affect
Thought Process:
- Organization, flow of ideas
- Linear vs. circumstantial vs. tangential
Thought Content:
- Preoccupations, obsessions, phobias
- Suicidal or homicidal ideation assessment
- Delusions or paranoid thoughts
Perception:
- Hallucinations (auditory, visual, tactile)
- Depersonalization or derealization
Cognition:
- Orientation to person, place, time
- Attention and concentration
- Memory assessment (immediate, recent, remote)
Insight and Judgment:
- Understanding of illness
- Decision-making capacity
Step 4: Risk Assessment
Critical component for any mental health case:
Suicide Risk Assessment:
- Current suicidal ideation, plan, means, intent
- Previous suicide attempts
- Protective factors vs. risk factors
Violence Risk Assessment:
- Homicidal ideation toward others
- History of violence or aggression
- Substance use contributing to risk
Functional Assessment:
- Ability to care for self
- Impact on work, relationships, daily activities
- Need for additional support or interventions
Step 5: Physical Examination Strategy
Perform focused physical exam to rule out medical causes:
Vital Signs:
- May show elevated HR, BP, RR during acute anxiety
- Temperature usually normal
Cardiovascular Examination:
- Auscultate heart for irregular rhythms
- Check for signs of hyperthyroidism
- Assess for heart murmurs
Neurological Assessment:
- Rule out neurological causes of anxiety
- Check reflexes and tremor
- Assess for signs of substance withdrawal
Additional Considerations:
- Thyroid palpation
- Look for signs of caffeine excess
- Assess for substance use indicators
Step 6: Developing Differential Diagnoses
Propose at least 3-4 appropriate differentials with rationales:
Primary Consideration: Generalized Anxiety Disorder
- Supporting evidence: 6-month history, excessive worry, physical symptoms, functional impairment
Secondary Considerations:
- Panic Disorder
- Consider: Acute episodes with physical symptoms
- Less likely: More chronic pattern, specific triggers identified
- Adjustment Disorder with Anxiety
- Consider: Related to stressors and life changes
- Less likely: Duration exceeds 6 months, symptoms disproportionate
- Medical Anxiety (Hyperthyroidism, Cardiac issues)
- Consider: Physical symptoms could suggest medical cause
- Less likely: Response to Lorazepam suggests psychiatric etiology
Step 7: Diagnostic Test Considerations
For anxiety presentations, consider:
Laboratory Studies (if indicated):
- TSH to rule out hyperthyroidism
- Basic metabolic panel
- Urine toxicology if substance use suspected
Rating Scales:
- GAD-7 for generalized anxiety
- Beck Anxiety Inventory
- Hamilton Anxiety Rating Scale
Medical Clearance:
- ECG if cardiac symptoms prominent
- Consider medical evaluation before psychiatric diagnosis
Step 8: Final Diagnosis and Most Significant Active Problem (MSAP)
Primary Diagnosis: Generalized Anxiety Disorder (GAD)
Justification:
- 6-month history of excessive worry and anxiety
- Physical symptoms interfering with daily functioning
- Multiple episodes per week
- Significant distress and functional impairment
- Meets DSM-5 criteria for GAD
MSAP Selection: Choose “Generalized Anxiety Disorder” as your Most Significant Active Problem, as this represents the primary condition requiring immediate mental health intervention.
Step 9: Comprehensive Treatment Plan
Develop a multi-modal treatment approach:
Immediate Safety Management:
- Risk assessment and safety planning
- Crisis resources and emergency contacts
- Consider short-term anxiolytic if needed
Pharmacological Interventions:
- First-line: SSRI therapy (sertraline 25mg daily, titrate)
- Alternative: Other SSRIs (escitalopram, paroxetine)
- Adjunct: Short-term benzodiazepine for acute symptoms
- Avoid: Long-term benzodiazepine dependence
Psychotherapeutic Interventions:
- Gold standard: Cognitive Behavioral Therapy (CBT)
- Alternative: Acceptance and Commitment Therapy (ACT)
- Group therapy: Consider anxiety support groups
- Mindfulness-based interventions
Lifestyle Modifications:
- Exercise: Regular aerobic activity 3-4x per week
- Sleep hygiene: Consistent sleep schedule, limit caffeine
- Stress management: Relaxation techniques, yoga, meditation
- Social support: Encourage connection with support system
Follow-up Plan:
- Primary care follow-up in 1-2 weeks
- Mental health referral within 1 week
- Monitor medication response and side effects
- Regular GAD-7 assessments to track progress
Step 10: SBAR Documentation
Create focused SBAR note for communication:
Situation:
- 32-year-old female teacher with acute anxiety symptoms
Background:
- 6-month history of recurrent anxiety episodes
- Triggered by schedule changes and stressors
- Previous inconsistent treatment
Assessment:
- Generalized Anxiety Disorder with moderate severity
- Good insight and no safety concerns
- Functional impairment affecting work and relationships
Recommendation:
- Initiate SSRI therapy and CBT referral
- Close follow-up and safety planning
- Consider psychiatric consultation if symptoms persist
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Anna Sink iHuman Case Summary
Grading Criteria:
The Anna Sink iHuman case will evaluate you across several critical domains to ensure comprehensive mental health assessment skills:
(1) Mental Status Examination (Major Points): You must conduct a thorough mental status exam to get full credit. Essential components include: appearance and behavior, speech assessment, mood and affect evaluation, thought process and content, perception, cognition, insight, and judgment. Don’t miss: suicide risk assessment, functional impairment evaluation, and symptom severity rating using standardized tools.
(2) History Taking (High Weight): Focus on anxiety-specific symptoms and triggers. Must-do components: detailed symptom history using anxiety-focused questions, trigger identification, functional impact assessment, and treatment history. Pro tip: The rubric awards points for exploring coping mechanisms and previous therapy experiences.
(3) Risk Assessment (Critical for Scoring): You need to assess suicide risk, violence potential, and functional capacity. Expected components include: direct questioning about self-harm, safety planning, protective factors identification, and level of care determination.
(4) Differential Diagnosis (Important): Propose at least 3 appropriate differentials with rationales. Expected differentials include: generalized anxiety disorder, panic disorder, adjustment disorder, and medical causes of anxiety. Scoring secret: The rubric rewards students who can distinguish between anxiety disorders based on symptom patterns and duration.
(5) Treatment Planning (Heavily Weighted): The rubric expects comprehensive treatment including: evidence-based psychotherapy referral (CBT), appropriate medication recommendations, lifestyle interventions, and follow-up planning. High-scoring responses mention: combination therapy approach and the importance of patient education.
(6) Communication and Documentation: Demonstrate therapeutic communication and professional documentation. Bonus points for: SBAR format mastery, crisis resource provision, and clear treatment rationale explanation.
Example of a High-Scoring Clinical Summary:
Patient Summary – Anna Sink
Situation: 32-year-old female teacher presenting with acute anxiety symptoms triggered by schedule changes, with 6-month history of recurrent episodes.
Background: Significant anxiety symptoms including chest tightness, palpitations, and hyperventilation occurring 1-2 times weekly. Previous inconsistent treatment with unclear medication compliance. No current safety concerns.
Assessment: Mental status exam notable for anxious mood with appropriate insight and no psychotic features. GAD-7 indicates moderate generalized anxiety disorder. Primary Diagnosis: Generalized Anxiety Disorder with significant functional impairment.
Recommendation:
- Initiate SSRI therapy (sertraline 25mg daily)
- Urgent CBT referral for anxiety management
- Patient education about anxiety disorders and coping strategies
- Follow-up in 1-2 weeks to assess treatment response
- Crisis resources provided with clear instructions for emergency situations
Patient Education Provided: Explained GAD pathophysiology, treatment options, and importance of consistent therapy. Provided coping strategies including grounding techniques and breathing exercises. Clear instructions given for crisis situations and when to seek immediate care.
Conclusion
By following this comprehensive approach to the Anna Sink case, you’ll demonstrate the mental health assessment skills that iHuman evaluates. Remember, success in psychiatric cases requires systematic thinking: gather detailed symptom history, perform thorough mental status examination, conduct appropriate risk assessment, consider medical differentials, and develop evidence-based treatment plans. The key is treating each iHuman simulation as you would a real patient encounter – be thorough, maintain therapeutic rapport, and always prioritize patient safety. With this guide, you’re well-prepared to excel in this challenging but essential mental health case simulation.
Frequently Asked Questions
What is the correct diagnosis for Anna Sink’s symptoms?
Anna Sink’s primary diagnosis is Generalized Anxiety Disorder (GAD). The key distinguishing features include her 6-month history of recurrent anxiety episodes occurring 1-2 times per week, accompanied by physical symptoms and fear of impending disaster. The GAD-7 assessment indicates moderate anxiety with significant functional impairment. Students often struggle between GAD and panic disorder, but GAD is characterized by persistent, excessive worry about multiple life domains, while panic disorder involves discrete panic attacks.
What are the critical mental status exam components I need to perform?
Essential mental status exam elements include assessing appearance and behavior, speech patterns, mood and affect, thought process and content, perception, cognition, insight, and judgment. Many students miss conducting proper suicide risk assessment and functional impairment evaluation, which are crucial for determining level of care needed. Don’t forget to use standardized assessment tools like the GAD-7 and document the patient’s insight into their condition.
How do I approach the SBAR documentation for social services?
The SBAR note should include: Situation (concise summary of presenting problem), Background (relevant history and triggers), Assessment (mental status findings and diagnosis), and Recommendations (treatment plan and follow-up). Focus on functional impairment, safety assessment, and specific interventions needed. Include key findings that support your diagnosis and justify the level of care recommended.
What treatment interventions should I include in my management plan?
Comprehensive treatment should address both immediate safety and long-term management. Include evidence-based psychotherapy referral (CBT is first-line for GAD), appropriate pharmacotherapy (SSRIs are first-line medication), lifestyle modifications (exercise, stress management, sleep hygiene), and structured follow-up plan. Students often forget to address the patient’s coping mechanisms and provide crisis resources, which are important for comprehensive anxiety management. Always include patient education about the condition and treatment options.