A 25-year-old woman is brought to the emergency department by coworkers following a 15-minute episode of chest pain, shortness of breath, and sweating that started while she was giving a presentation. She is very anxious and says, "It happened so suddenly; my heart was pounding, and I felt like I was going to pass out." The patient first had a similar episode 3 months ago prior to giving a presentation at work and has had a number of episodes since then-while socializing with friends, before taking a flight to visit her parents, and while relaxing at home with her roommate. Now she constantly worries about having another episode. The patient is extremely anxious about speaking in public and has called in sick twice to avoid giving presentations, fearing that the symptoms will recur. She has a history of a benign childhood heart murmur, asthma, and hypothyroidism. Medications include levothyroxine and an albuterol inhaler that she uses infrequently. Temperature is 37 C (98.6 F), blood pressure is 130/85 mm Hg, pulse is 98/min, and respirations are 18/min. Examination shows mild end-expiratory wheezing over the left lower lobe and no other abnormalities. White blood cell count is 9,800/mm³ and TSH level is 4.2 µU/mL. Which of the following is the most likely diagnosis?

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11ec25c8_d7dc_ee96_bc81_fb26701d729b_MD0003_00 This patient's abrupt onset of intense episodes of anxiety accompanied by chest pain, shortness of breath, sweating, and dizziness is suggestive of panic disorder. Diagnosis requires that at least some of these panic attacks are untriggered or unexpected (eg, at home, relaxing with friends) and the presence of ≥1 months of worry about future attacks or change in behavior (eg, avoidance). Panic attacks may also be a symptom of other anxiety disorders; however, in these cases the panic attacks are always specifically triggered by a feared object or situation (eg, being away from home alone in agoraphobia; being in social or performance situations in social anxiety disorder) (Choices A and F). The key difference is that in panic disorder, at least some attacks are unexpected and followed by persistent worry about future attacks. (Choice B) Anxiety disorder due to another medical condition is diagnosed when the panic attacks are a direct physiological consequence of another medical condition (eg, hyperthyroidism, arrhythmias, asthma). This patient's thyroid condition is stable and her asthma attacks are infrequent and not consistently related to her panic attacks. Her mild wheezing on examination is more likely a consequence than a cause of her panic. (Choice C) Generalized anxiety disorder is characterized by ≥6 months of persistent worry about multiple issues and does not feature unexpected panic attacks. Patients with panic disorder may exhibit some degree of chronic anxiety, but this is due to fears of having additional attacks, not excessive anxiety about everyday issues. (Choice D) Medication-induced anxiety disorder is diagnosed when panic symptoms are directly caused by exposure to a medication (eg, overmedication with albuterol or levothyroxine, precipitating panic). However, this patient's TSH level is normal and she is using albuterol infrequently, making these unlikely causes of her recurrent attacks. Educational objective: Panic disorder involves recurrent unexpected panic attacks, fears of future attacks, and avoidance behavior. Diagnosis requires differentiation from other anxiety disorders that may include triggered panic attacks and ruling out medical causes. References: Diagnosis and management of generalized anxiety disorder and panic disorder in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25955736) A brief interview to detect panic attacks and panic disorder in emergency department patients with cardiopulmonary complaints. (http://www.ncbi.nlm.nih.gov/pubmed/29320381)

A 25-Year-Old Woman Is Brought to the Emergency Department by Coworkers