A 28-year-old woman requests an emergency office appointment after an episode of palpitations, dizziness, chest pain, and nausea while giving a presentation at work. The patient says, "I suddenly felt dizzy and my chest was pounding. My hands and legs were tingling and I was afraid I was going to pass out." She describes several similar episodes over the past several months and worries about having another episode. She says, "I am especially afraid when it happens at work because it is so embarrassing, but it even happens when I am home doing nothing." The patient has no significant medical history. She drinks a glass of wine 3 or 4 times a week and takes no medications. Family history is significant for coronary artery disease in her father and endometrial cancer and depression in her mother.
The patient appears anxious and is mildly diaphoretic. She is initially tachycardic, but repeat vital signs are within normal limits. Physical examination is unremarkable.
Which of the following is the most likely diagnosis?

Question

A 28-year-old woman requests an emergency office appointment after an episode of palpitations, dizziness, chest pain, and nausea while giving a presentation at work.  The patient says, "I suddenly felt dizzy and my chest was pounding.  My hands and legs were tingling and I was afraid I was going to pass out."  She describes several similar episodes over the past several months and worries about having another episode.  She says, "I am especially afraid when it happens at work because it is so embarrassing, but it even happens when I am home doing nothing."  The patient has no significant medical history.  She drinks a glass of wine 3 or 4 times a week and takes no medications.  Family history is significant for coronary artery disease in her father and endometrial cancer and depression in her mother.
The patient appears anxious and is mildly diaphoretic.  She is initially tachycardic, but repeat vital signs are within normal limits.  Physical examination is unremarkable.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_98bd_67f7_853d_77239e5a5b56_MD0002_00 Recurrent episodes of anxiety, palpitations, chest pain, dizziness, and nausea in a young, otherwise healthy patient are most likely due to panic disorder. Panic disorder is characterized by abrupt onset, short duration (<10 minutes), and prominent physical symptoms that frequently prompt patients to seek emergency medical care. Patients develop fears of having additional attacks and/or avoidance behavior. Panic disorder must be differentiated from medical conditions that produce similar symptoms, including cardiac and pulmonary disorders, hyperthyroidism, pheochromocytoma, hypoglycemia, and effects of both prescribed and illicit substances. Panic disorder must also be differentiated from other anxiety and psychiatric disorders that can have infrequent panic attacks as an associated feature. A key distinguishing feature of panic disorder is unexpected panic attacks at some point in the illness, in contrast to other disorders in which panic attacks are always triggered by specific situations. (Choices A and C) Paroxysmal supraventricular tachycardia is usually not associated with gastrointestinal distress or paresthesias. Mitral valve prolapse is associated with abnormalities on cardiac examination (eg, non-ejection click, mitral regurgitation murmur) that are not present in this patient. (Choice D) In performance anxiety, panic attacks are limited to the feared performance situation. This patient's anxiety attacks have also occurred unexpectedly while she is resting at home. (Choice E) Patients with panic disorder and somatic symptom disorder have multiple physical symptoms and high health care use. However, this patient's physical symptoms are classic for panic disorder, and there is no evidence of excessive preoccupation with somatic symptoms prior to or apart from her panic episodes. Educational objective: Panic disorder involves recurrent, unexpected anxiety attacks characterized by abrupt onset, short duration, and prominent physical symptoms. Diagnosis requires ruling out medical and substance-induced causes as well as other psychiatric disorders that can include infrequent, situationally triggered panic attacks. __________ References: Diagnosis and management of generalized anxiety disorder and panic disorder in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25955736) Panic disorder (attack). (http://www.ncbi.nlm.nih.gov/pubmed/28613692)

A 28-Year-Old Woman Requests an Emergency Office Appointment After an Episode