Chronic Upper Abdominal Discomfort and Dyspnea in a Young Adult with Anxiety

Case at a Glance

A 20-year-old female presents with a 2-year history of upper abdominal discomfort, sensation of constriction, and significant breathing difficulties that have severely impacted her quality of life. The patient has a concurrent anxiety disorder that has prevented medical evaluation.

Patient's Story

The patient is a 20-year-old female, 5'8" tall, weighing 150 lbs, who developed sudden onset of upper abdominal symptoms approximately 2 years ago. She describes a persistent sensation of something 'blocking or squeezing' her upper abdomen, particularly noticeable during rest. The patient reports significant dyspnea, describing breathing as requiring constant conscious effort rather than being automatic. She experiences particular difficulty with expiration, feeling unable to fully exhale or complete the exhalation process normally. Activities requiring prolonged expiration such as laughing or crying become impossible after 3 seconds due to discomfort and the sensation of abdominal constriction. These symptoms are constant, occurring throughout each day for the past 18 months without relief. The patient notes that her pre-existing anxiety disorder has been exacerbated by these symptoms, as she cannot use breathing techniques to manage anxiety episodes. She reports severe anxiety symptoms including tachycardia (heart rate reaching 180 bpm), nausea, tremors, paresthesias, presyncope, and chest pain, which have resulted in agoraphobia for the past 3 years, preventing medical evaluation.

Initial Assessment

The patient has not undergone formal medical evaluation due to anxiety-related agoraphobia. Self-assessment reveals isolated respiratory and upper abdominal symptoms without associated gastrointestinal complaints such as heartburn, regurgitation, or dysphagia that would typically accompany hiatal hernia.

The Diagnostic Journey

The patient independently researched her symptoms and considered hiatal hernia as a potential diagnosis, though noted the absence of typical associated symptoms. Medical consultation noted that hiatal hernias classically present with GERD symptoms and heartburn rather than isolated dyspnea and abdominal constriction.

Final Diagnosis

Pending comprehensive medical evaluation including physical examination, imaging studies, and pulmonary function testing. Differential diagnosis includes hiatal hernia, diaphragmatic dysfunction, anxiety-related breathing pattern disorder, or other structural abnormalities affecting the diaphragm or upper abdomen.

Treatment Plan

Immediate priority is establishing medical care despite the patient's anxiety disorder. Recommendations include coordinated approach with primary care physician for initial workup, potential anxiolytic support to enable medical evaluation, and consideration of telemedicine options if available. Diagnostic workup should include chest imaging, upper GI studies if indicated, and pulmonary function assessment.

Outcome and Follow-up

Patient education provided regarding the importance of medical evaluation despite anxiety barriers. Emphasis placed on the fact that hiatal hernias typically present with heartburn and GERD symptoms rather than isolated breathing difficulties. Follow-up pending patient's ability to overcome anxiety-related barriers to seeking medical care.