A 22-year-old woman comes to the emergency department for acute onset of nausea and diarrhea. By the time the patient is seen, the abdominal distress has resolved, but she remains agitated and is certain "there is something really wrong with me." Over the past 2 months, the patient has had 4 similar episodes during which she experienced a sudden sinking feeling in her stomach, accompanied by nausea, sweating, rapid heart rate, and shortness of breath. On 2 occasions, these symptoms were also accompanied by diarrhea. She has become increasingly fearful of leaving her home and tearfully reports, "I am going to lose my job." The patient works as a receptionist and has called in sick 5 times in the past 4 weeks because she fears having an episode at work. She does not use illicit drugs. Medical history is unremarkable. Temperature is 37 C (98.6 F), blood pressure is 121/77 mm Hg, pulse is 87/min, and respirations are 14/min. Physical examination is within normal limits and laboratory results are unremarkable. While awaiting discharge, the patient suddenly feels nauseous again. Her breath becomes shallow and rapid. She sweats profusely and says, "My heart is pounding…going to die." Which of the following is the most appropriate immediate step in management of this patient?

Question

A 22-year-old woman comes to the emergency department for acute onset of nausea and diarrhea.  By the time the patient is seen, the abdominal distress has resolved, but she remains agitated and is certain "there is something really wrong with me."  Over the past 2 months, the patient has had 4 similar episodes during which she experienced a sudden sinking feeling in her stomach, accompanied by nausea, sweating, rapid heart rate, and shortness of breath.  On 2 occasions, these symptoms were also accompanied by diarrhea.  She has become increasingly fearful of leaving her home and tearfully reports, "I am going to lose my job."  The patient works as a receptionist and has called in sick 5 times in the past 4 weeks because she fears having an episode at work.  She does not use illicit drugs.  Medical history is unremarkable.  Temperature is 37 C (98.6 F), blood pressure is 121/77 mm Hg, pulse is 87/min, and respirations are 14/min.  Physical examination is within normal limits and laboratory results are unremarkable.  While awaiting discharge, the patient suddenly feels nauseous again.  Her breath becomes shallow and rapid.  She sweats profusely and says, "My heart is pounding…going to die."  Which of the following is the most appropriate immediate step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d7dc_5255_bc81_45cd2f150f3c_MD0003_00 The presence of recurrent episodes of abdominal distress, diaphoresis, shortness of breath, racing heart, and severe anxiety in an otherwise healthy young adult with a negative medical workup is suggestive of panic disorder. Panic disorder involves both panic attacks and persistent concern about additional attacks and/or a change in behavior to avoid having another attack. Panic disorder may present with a wide array of physical symptoms, with some patients coming to the emergency department with fears that they may be very ill (eg, having a heart attack) or dying. The long-term treatment of panic disorder may include antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors, and/or cognitive-behavioral therapy; however, both interventions require weeks to take effect and would not alleviate this patient's immediate symptoms and marked distress (Choices B and C). Benzodiazepines (eg, lorazepam) can provide rapid relief of panic attacks and can also be used in the short term while waiting for an SSRI to take effect. Due to the risks of misuse and addiction, they should be prescribed cautiously in patients with a history of a substance use disorder. (Choice A) Buspirone is an anxiolytic used in the treatment of generalized anxiety disorder. It is not effective in the management of acute anxiety and is not used to treat panic disorder. (Choices E and F) This patient's history of recurrent episodes of nausea that resolve spontaneously is consistent with panic attacks, and her physical examination and laboratory results do not point to an alternative explanation. The proton pump inhibitor omeprazole may be used in the treatment of conditions such as gastroesophageal reflux disease. Ondansetron is a 5-HT₃ receptor antagonist antiemetic that is used in patients with persistent nausea. (Choice G) The nonselective beta-blocker propranolol is sometimes used for performance anxiety but there is no evidence of benefit in panic attacks. Educational objective: Benzodiazepines provide rapid relief of anxiety and are indicated for the management of acutely symptomatic and functionally impaired patients with panic disorder. Antidepressants and cognitive-behavioral therapy are preferred for long-term treatment. References: Pharmacological treatment of panic disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25225023) Diagnosis and management of generalized anxiety disorder and panic disorder in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25955736)

A 22-Year-Old Woman Comes to the Emergency Department for Acute